病人安全系統的回顧與建議

A systematic Review and Some Suggestious of Patiout Safety

自1999 年美國醫學研究機構（10M） 揭槳病人安全的議題後，世界各地 都逐漸警示到其重要性。台灣亦於2003 年開始由衛生署及醫策會主導，展開 了一系列的演說、教育與研討會，期使社會大眾及醫療從業人員等能認識到 病人安全的重要性，進而投入研究，進行改善，以達到增進就醫安全的目 的。但是，觀諸這一年多來的進展，雖然各項研討會不斷，各種建議也紛會 而來，有關病人安全的研究與改善卻進步有限。究其原因在於名詞定義的混 淆，對議題未能清楚釐清，缺乏主導的機構，以及手段和目標不明確等等。 本文嘗試將病人安全的議題做一有系統的回顧，對台灣近幾年幾件有名 的醫療不良事件加以檢閱，對各項名詞的中英文名稱和定義做詳盡地闡述， 最後再提出我們認為建立病人安全所應使用的方法和目標。祥使所有有心改 善病人安全的各醫療單位，醫療主導機關，以及欲從事此項研究的專家學者 有所遵循和參考。

Since 1999, the American Institute of Medicine (IOM) has revealed the issue of patient safety. The whole world begins being aware of the severity of it. In Taiwan, the Department of Health and the Taiwan Joint Commission on Hospital Accreditation (TJCHA) have directed this issue since 2003 and have held a series of addresses, education courses and symposiums to awaken our people and medical professionals to beef up our safety system. The progress of patient safety, however, is limited despite of a lot of efforts. The root causes are the confusion of terminology and definitions relative to patient safety and the succeeding puzzles of the issue, and the deficiency of a leading organization, and inexplicit methods and destinations. This article tries to review the issue of patient safety systemically. Meanwhile we looked over some famous adverse events occurred in these two years in Taiwan. And, we ve made explicit explanations of some terms mostly used and would translate them to Chinese. The verities of adverse events including diagnostic aspect, therapeutic aspect, preventive aspect, were tagged and listed. The causes of adverse events were fully analyzed and discussed. The contemporary methods for studying errors like MTO, DEB, RCA, etc. have been reviewed too. We also compared the goals of patient safety recommended by JCAHO in 2004 with the goals presented by our Department of Health. In the end of this article, we have proposed some practical methods to build a safer system. In that way, we hope we can establish a guide for all intended health care organizations, regulators and accreditors, and experts to do further researches.