運用根本原因分析提升門診手術病患安全查核方案

Application of Root Cause Analysis to Improve the Safety for Outpatient Surgery

本專案旨在改善門診手術病患安全查核作業，運用根本原因分析（Root Cause Analysis）辨識門診手術部位錯誤之原由為：醫師未遵守手術前作業流程、未落實門診手術病患安全查核、教育訓練不足與缺乏門診手術病患安全作業規範。專案成員依據根本原因擬定具體改善方案包括：舉辦手術病人安全相關在職教育、制定手術安全作業規範、修改門診手術病患安全查核表及建立稽核制度。評值結果：醫師手術前作業完整率、手術病患安全查核與暫停確認（Time Out）執行率皆達100%。本專案不僅改善門診手術病患查核流程，也希望藉由本專案經驗分享推廣至全院各單位，進而維護病人就醫安全。

This project aimed to improve the safety in outpatient surgery. To do this, root cause analysis was applied to identify the causes of site error. The causes were noncompliance with the pre-operational procedures, inappropriate safety checking for outpatient surgery, insufficient training, and a lack of standard operating procedures for outpatient surgery. Based on these findings, we began a continuing education focus on surgery safety for patients, designed standard operating procedures to protect surgical patient safety, revised the safety checklist for outpatient surgery, and established an auditing system. The outcomes of completeness of pre-operative procedure for doctors, safety checklist of outpatient surgery for nurses, and performance of time out were achieved one hundred percent. This project not only improved the safety checklist for outpatient surgery but also served as a reminder to our healthcare professionals of the importance of patient safety f. The results of this project can be applied to the other units of hospital. Root cause analysis can be applied to the other adverse event reports to further maintain patient, safety.