利用RCA與HFMEA提升電腦斷層檢查安全

Enhancing CT Examination Safety through RCA and HFMEA

影像醫學科電腦斷層檢查依病人來源分為「急做」及「排程」兩個流程，若工作人員未依臨床醫師指示執行檢查，會造成病人承受額外輻射劑量與不必要之顯影劑；近一年內，本科發生兩件急診電腦斷層檢查「未正確執行醫令」異常事件，經團隊與主管討論後，決定以「根本原因分析」來探討「急做」流程失誤問題的根本原因，並利用「失效模式與效應分析」來檢視「排程」流程的潛在風險，從而識別出適合的解決方案；經導入5大對策群組：包含流程修訂、目視化應用、雙重覆核及5S管理等10項改善對策，「急做」檢查流程未再發生相關異常事件、「排程」檢查流程之危害優先數由52降低至22，電腦斷層檢查整體病人安全大大地提升。

Based on patient feedback, CT examinations are divided into two processes: emergent and scheduled. If radiation technologists fail to follow clinicians' instructions during the examination, patients may receive additional radiation and contrast. Last year, there were two incidents where instructions from doctors were not accurately followed during emergent CT examinations. Following discussions with the manager and team, we decided to investigate the root cause of these mistakes using Root Cause Analysis (RCA). Additionally, we utilized Healthcare Failure Mode and Effect Analysis (HFMEA) to assess potential risks in the scheduled process of CT examinations. Through these investigations, we aimed to identify appropriate solutions.
By implementing ten strategies grouped into five countermeasure clusters, including process revision, visual application, double checking, 5S management, and more, we have successfully eliminated incidents in the emergent process. Moreover, the risk priority number of the scheduled process has been reduced from 52 to 22. This significant improvement demonstrates a substantial promotion in the safety of patients undergoing CT examinations.