化學治療給藥之失效模式與效應分析

Failure Mode and Effect Analysis: Application in Chemotherapy

以病人為中心的醫療照護模式，是醫療服務強調的重點，失效模式與效應分析是屬於預應式、質化的處理分析技術，Joint Commission Accredited of Health Organization (JCAHO)於2002年開始，要求轄管醫療機構至少每年選擇一項高風險的照護流程，執行預防性的風險評估作業，以達到辨識風險在先，防止意外事故發生，失效模式與效應分析是JCAHO指定的風險評估技術，本專案即運用失效模式與效應分析(Failure mode and effect analysis, FMEA)，分析評估化學治療給藥的潛在風險，發現主要化學治療給藥失效模式有三點：(1)化學治療給藥作業欠周詳；(2)溝通障礙；(3)護理人員教育訓練不足。期望透過化療FMEA之應用介紹，促進醫療人員運用FMEA的普及與熟練度，進而提升人員對潛在風險的敏感度與預應改善能力，達到保障病人安全之目的。

Medical institutions are increasingly concerned about ensuring the safety of patients under their care. Failure mode and effect analysis (FMEA) is a qualitative approach based on a proactive process. Strongly promoted by the Joint Commission Accredited of Health Organization (JCAHO) since 2002, FMEA has since been adopted and widely practiced in healthcare organizations to assess and analyze clinical error events. FMEA has proven to be an effective method of minimizing errors in both manufacturing and healthcare industries. It predicts failure points in systems and allows an organization to address proactively the causes of problems and prioritize improvement strategies. The application of FMEA in chemotherapy at our department identified three main failure points: (1) inappropriate chemotherapy standard operating procedures (SOPs), (2) communication barriers, and (3) insufficient training of nurses. The application of FMEA in chemotherapy is expected to enhance the sensitivity and proactive abilities of healthcare practitioners during potentially risky situations as well as to improve levels of patient care safety.