運用「醫療失效模式與效應分析」提升加護病房中心靜脈導管照護品質

Using Healthcare Failure Mode and Effect Analysis to improve Central Venous Catheter Care Quality in an Intensive Care Unit

本研究目的在運用醫療失效模式與效應分析評估「中心靜脈導管照護流程」潛在 風險因子，並提出改善方案。HFMEA是目前運用於醫療流程的風險評估手法之一。 中心靜脈導管是時常用於重症照護的醫療處置，然而，中心靜脈導管相關血流感 染同時也是加護病房常見的感染。透過流程的分析發現改善前有十五項失效原因需加 以改善，改善後各項模式皆有衡量控制方式，且中心靜脈導管相關血流感染率由2.7‰ 下降至0‰。未來仍將持續加強同仁宣導，以落實中心靜脈導管安全，為病人安全把 關。 增進病人安全需要團隊的努力，而此種具系統性及連續性的前瞻性風險分析方 法，目的就是希望在危害尚未造成前，便可因流程改善而避免，可有效提高醫療品質 及確保病人安全。

This study aimed to identify the potential risk factors of central venous catheter care process by using the analytical tool of Healthcare Failure Mode and Effect Analysis (HFMEA). Besides that, this study will also provide recommended corrective actions by using HFMEA, which is one of the most popular assessment tools in identifying risk factors of medical procedure. While the central line catheter is a common device used in intensive medical care, it is a frequent source of nosocomial infection. There were 15 potential causes been identified by HFMEA procedure assessment; it also generates measurement and control strategies for every failure modes. After implementing corrective actions, the rate of central venous catheter associated bloodstream Infection has significantly decreased from 2.7‰ to 0‰. The evaluated hospital had set up central venous catheter safety guidance, which has been put into staff training program to ensure every employee have a better knowledge of patient safety. It takes a team’s effort to continuously improve patient safety, and HFMEA is a systematic, continuous and proactive risk analysis method to avoid damages from happening by finding potential pitfalls and doing procedure corrections. As the result, it could effectively improve the quality of healthcare and ensure patients’ safety.