運用醫療照護失效模式與效應分析模式提升腦室外引流管術後照護品質

Using Healthcare Failure Mode & Effects Analysis(HFMEA) to Enhance the Postoperative Care Quality of External Ventricular Drain

腦室外引流管(external ventricular drain, EVD)為神經外科加護病房常見管路，本單位2022年1月至6月有3件照護跡近錯誤發生，雖未造成病人傷害，但有管路安全風險，引發改善動機。本案2022年12月至2023年3月運用醫療照護失效模式與效應分析(healthcare failure mode & effects analysis, HFMEA)手法，檢視照護流程找出12項流程缺失處，提出預防措施與對策方案：設計提升照護流程順暢性工具、制定一致性照護紀錄單、舉辦實體及數位學習課程、建立安全稽核制度等。實行後風險指數由110分降至44分，改善率達60%、流程缺失降為0項，至2024年3月31日止，單位無相關跡近錯誤事件。驗證此手法能有效提升照護完整性及管路安全，希將對策內容及學習工具，平行推廣至其它加護病房，讓此類病患能夠得到更完善及安全的照護。

External ventricular drain (EVD) is a common tubing system in neurosurgical intensive care units. Between January and June 2022, our unit experienced three near-miss incidents related to care. Although these incidents did not result in patient harm, they posed risks to patient and tubing safety, prompting us to initiate improvement efforts. From December 2022 to March 2023, this study utilized the Healthcare Failure Mode and Effect Analysis (HFMEA) method to examine care processes, identify potential problems based on hazard analysis, and propose appropriate preventive measures and strategies. These included designing tools to enhance the smoothness of care processes, establishing care nursing record sheets, organizing physical and digital learning courses, and implementing a safety audit system. Following implementation, the risk index decreased from 110 to 44, achieving a 60% improvement rate. The number of process deficiencies decreased from 12 to 0. As of March 31, 2024, there have been no near-miss incidents related to EVD in our unit, effectively enhancing the integrity of EVD care and patient catheter safety. We aim to extend these improvements to other intensive care units within the hospital, ensuring that patients in similar conditions receive more comprehensive and safer care.