以醫療失效模式與效應分析改善中醫毫針刺出入針數不符之風險

The use of healthcare failure mode and effect analysis to lower the risk of inconsistent needle counts

目的：針刺出入針數不符是中醫臨床常見之異常事件，本研究的目的是運用失效模式與效應分析以提升中醫毫針刺的安全與出入針數之正確性。材料與方法：根據醫療失效模式與效應分析方法，執行針刺流程檢視與針刺步驟之危害分析，找出中醫毫針刺出入針數不符之潛在失效模式及原因，觀察並以描述性統計比較執行前後的差異。結果：護理師未能正確協助病人準備毫針刺姿勢及露出毫針刺之危害指數由9 分降為4 分，改善率為55.6%。醫師未正確計算毫針入針數之危害指數由12 分降為4 分，改善率達66.7%。護理人員執行取針作業有遺漏之危害指數也由9 分降為6 分，改善率達33.3%。中醫門診針刺出入針數不符比率由0.231% 改善為0.16%。討論與結論：中醫醫療失效模式與效應分析的介入，可提升護理師中醫毫針刺穴位認知及醫師毫針數針之正確性，有助於改善中醫毫針刺出入針數不符之風險與病人安全。

 

Aim: Inconsistent needle count is a common clinical problem in acupuncture. The purpose of this study was to use healthcare failure mode and effect analysis (HFMEA) to improve acupuncture safety and needle count accuracy. Materials and Methods: In accordance with the HFMEA method, we reviewed the acupuncture procedure with hazard analysis to identify potential failure modes and causes of inconsistent needle counts. We used descriptive statistics to compare differences before and after HFMEA. Results: The hazard index of “nursing assistant failed to properly assist patients in preparing for acupuncture stance and exposing the naked needle” dropped from 9 to 4 points, with a 55.6% improvement rate. Another hazard index of “physician incorrectly calculating the number of needles” reduced from 12 to 4 points, with an improvement rate of 66.7%. The hazard index of “needle missing from nurses picking operation”decreased from 9 to 6 points, with an improvement rate of 33.3%. The mismatch rate of acupuncture needles in outpatients decreased from 0.231% to 0.16%.