運用人為因素分析改善抗凝血劑不良事件

Using Root Cause Analysis to Improve Adverse Events of Anticoagulants

目的：本研究以中部某醫學中心發生不預期心跳停止事件個案為例，運用根本原因分析法（Root Cause Analysis, RCA）了解造成偏差之過程及原因，進一步檢討及改善程序，降低院內類似事件之發生率。
方法：運用人為因素分析與分類系統（Human Factors Analysis and Classification System, HFACS）分析近端原因，以原因樹（Why Tree）分析根本原因為：一、醫師教育訓練不足。二、醫療團隊間溝通不良。三、無抗凝血劑復藥提醒機制。
結果：個案醫院於2023年1月15日進行全院宣導，修訂「介入性檢查及治療抗凝血劑使用停用及輸血指引」，並建置於系統內供同仁們參考，加強醫師相關藥物使用之繼續教育。另外，於2023年4月17日修改醫囑系統，建立抗凝血劑資訊系統復藥提醒機制，新增是否停藥提醒及停藥天數建議、手術後復藥自動帶入交班系統內直至完成復藥醫囑。個案醫院追蹤至2023年12月31日，未再發生類似案件，且復藥比率由79.3%提升至81.7%。
結論：人為因素分析為一有效分析工具，可以找出不良事件根本原因，重新檢視並在系統設立抗凝血劑停復藥提醒機制，建置標準流程，以保障病人安全，提升醫療照護品質。

Purpose: This research takes a case of unexpected cardiac arrest at a medical center in central Taiwan as an example. We use Root Cause Analysis (RCA) to analyze the process and causes of the deviation. We strive to review and improve procedures to reduce the occurrence rate of similar events within the hospital.
Methods：We use the Human Factors Analysis and Classification System (HFACS) to analyze the proximal causes. In addition, we use why tree analysis to identify the root causes as 1.insufficient physician education and training, 2.lack of reminders for anticoagulant re-administration, and 3.poor communication among the medical team. Countermeasures included 1.revising the ''Guidelines for Discontinuation of Anticoagulant and Blood Transfusion for Interventional Examination and Surgical Treatment.'' and promoting them throughout the hospital for reference within the system, and 2.establishing a reminder mechanism for anticoagulant re-administration in the Hosiptal Information System (HIS). Results：The hospital conducted a hospital-wide education session on January 15, 2023, revising the ''Guidelines for Discontinuation of Anticoagulant and Blood Transfusion for Interventional Examination and Surgical Treatment.'' The guidelines were made available in the system for reference, and continuing education on the use of relevant medications was provided to physicians. Additionally, on April 17, 2023, the hospital updated the Computerized Provider Order Entry (CPOE) system by establishing a reminder mechanism for anticoagulant resumption. This update included suggestions on whether to discontinue the medication and the number of days for discontinuation, as well as the automatic entry of anticoagulant resumption into the handover system after surgery, continuing until the resumption order was completed. The hospital tracked cases until December 31, 2023, during which no similar incidents occurred, and the rate of anticoagulant resumption improved from 79.3% to 81.7%.
Conclusion：Human factors analysis is an effective tool for identifying the root causes of adverse events. By re-evaluating and establishing standardized procedures for the use and discontinuation of anticoagulants within the system, we can ensure patient safety and improve the quality of medical care.