運用HFMEA手法降低血液透析室水處理之菌落數

Using HFMEA to Reduce the Number of Colonies in the Water of Hemodialysis Room

運用HFMEA手法降低血液透析室水處理之菌落數
國內血液透析中心發生多起透析用水處理不當導致的醫療疏失，讓醫病關係產生緊張及不信任感。本單位2018年04月至09月因透析液送檢不合格率為0.2%，故成立專案小組藉由醫療失效模式效應分析，檢視透析用水處理流程。發現問題有：漂白水濃度不足、漂白水靜置時間不足、透析機無自動開機沖洗、班間沖洗時間不足、透析機消毒時未吸取消毒液、透析機移動重新接水路未執行沖洗、透析用水採檢技術流程知識不足等問題，其改善措施為：修訂水處理系統消毒規範、修訂透析機消毒規範、修訂透析用水採檢流程。對策實施後，不合格率由0.2％降至為0％，高為險因子由10項降低為0項。藉此次專案讓人員瞭解HFMEA是著重於系統分析，可預防錯誤發生進而提升醫療安全。

 

Many cases of medical negligence caused by improper treatment of dialysis water occurred in domestic hemodialysis centers, which caused tension and mistrust between doctors and patients. From April to September 2018, the unqualified rate of dialysate was 0.2% in our hemodialysis room. Therefore, a task force team was set up to examine the dialysis water treatment process through the analysis of medical failure mode effects. We found problems that include: insufficient concentration of bleach water, insufficient standing time of bleach water, no automatic start-up flushing of the dialysis machine, insufficient flushing time between shifts, no antiseptic solution was absorbed during the disinfection of the dialysis machine, flushing was not performed when the dialysis machine was moved and reconnected to the water circuit and insufficient knowledge of the technical process of sampling of dialysis water. The measures of improvement are revising the disinfection specification of water treatment system, revising the disinfection specification of dialysis machine, and revising the sampling process of dialysis water. After the implementation of the countermeasures, the unqualified rate was reduced from 0.2% to 0%, and the high risk factors were reduced from 10 to 0. Through this project, personnel can understand that HFMEA focuses on system analysis, which can prevent errors and improve medical safety.