運用醫療照護失效模式與效應分析提昇檢查室及放射科檢查轉送安全

Improvements in Transport Safety Using Healthcare Failure Mode and Effect Analysis in the General Examination Room and Radiology Room

本專案採用醫療照護失效模式與效應分析(Healthcare Failure Mode and Effect Analysis, HFMEA)模式進行跨部門間的風險管理，以改善某區域教學醫院檢查病人轉送流程，降低轉送安全異常率及改善病人危害嚴重度。依據HFMEA模式進行分析，主因為送檢前病人準備不齊全、轉送人員未確實執行病人辨識、轉送流程規範不齊及無稽核機制、資訊系統功能不足；故加強人員教育訓練及落實病人辨識、修訂轉送流程規範及建立稽核制度、建構轉送安全交班資訊化系統以利即時聯繫。回溯2016年轉送檢查異常事件，篩選出19項潛在失效原因，執行改善後高風險因子降為2個，轉送安全異常率降至0.02%，病人危害三級嚴重度降至15.4%。透過此專案推展可降低病人檢查轉送安全異常率及危害嚴重度，亦可維護病人安全及提升照護品質，以避免重大風險發生。

We conducted a healthcare failure mode and effect analysis (HFMEA) to improve the safety of patient transport in the general examination room and radiology room at a southern regional hospital in Tainan City, Taiwan. We also sought to reduce rates of reported abnormalities in patient safety in the hospital’s notification system and improve the patient hazard severity. To do this, we strengthened personnel education training, implemented patient identification practices, revised the norms of transport process establishing an audit system, and constructed a transport safety shift information system to facilitate timely communication. To evaluate the outcomes, we reviewed the transport safety abnormal events in 2016 and screened them for 19 potential causes of failure. After the improvement measures were implemented, the risk factors for high risk decreased to 2, rate of reported patient check and transfer safety abnormalities was reduced to 0.02%, and the rate of level 3 hazard severity was reduced to 15.4%. In conclusion, our efforts enabled us to reduce the abnormal rate of patient check, transport safety procedures and hazard severity, which led to better maintenance of patient safety and improved quality of care. Our efforts led to a consensus between registered nurses and transfer personnel regarding the best way to ensure transfer safety protection and improve and maintain patient safety by avoiding major risks.