運用失效模式與效應分析，降低病房多重抗藥性菌株照護流程的風險係數

Applying Healthcare Failure Mode and Effect Analysis to the Risk Factor of the Care Process of Multiple Drug Resistant Strains in the Ward

"多重抗藥菌株照護是重要及不容許院內感染發生，運用失效模式與效應分析（Failure Mode and Effects Analysis, FMEA），評估本院住院中病人，多重抗藥性菌株照護流程失效模式：隔離床位運用不周全、缺乏多重抗藥性菌株照護指引、執行手部衛生正確率低、環境清潔未落實等，經專案小組收集相關資料後，整理出以危害風險指數（RPN）大於100分潛在失效項目擬定對策，包括：調整隔離床位運用效能、隔離不害怕之多重抗藥性菌株照護指引、推動手部衛生稽核之蟲蟲拜拜辦法、專人環境清潔我最行等策略，以降低本院住院中病人多重抗藥菌株交叉感染風險為本專案目的。結果：危害風險指數由1415下降至366，改善成效達74.1％；鎖床由266床／月降低為157床／月（40.0％）；手部衛生不正確率由14.7％降低為2.0％；住院中多重抗藥性菌株感染環境清潔不正確率28.4％降低為10.8％。"

Multidrug-resistant organisms care is important and no hospital infections are allowed, Using Failure Mode and Effects Analysis, assessment of patients in our hospital, Failure modes of the multidrug-resistant organisms care process: incomplete use of isolation beds, lack of care guidelines for multidrug-resistant organisms, low accuracy in implementing hand hygiene, and unimplemented environmental cleanliness, etc. After the task team collected relevant information, the hazard risk index (RPN) Proposed countermeasures for potential failure items greater than 100 points, including: adjusting the efficiency of the isolation bed, the guidelines for the care of multi-drug resistant strains that are not afraid of isolation, the worm worship method for promoting hand hygiene audits, and the best way to clean the environment by dedicated personnel to reduce The risk of cross-infection of multidrug-resistant organisms in hospitalized patients in this hospital is the purpose of this project. Result: The hazard risk index decreased from 1415 to 366, and the improvement effect reached 74.1%; the locked bed was reduced from 266 beds/ month to 157 beds/month (40.0%) ; the incorrect hand hygiene rate was reduced from 14.7% to 2.0%; in hospital The rate of incorrect cleaning of the multidrug-resistant organisms infected environment was reduced from 28.4% to 10.8%.