運用醫療照護失效模式與效應分析降低關節置換術後靜脈血栓

Using Healthcare Failure Mode & Effects Analysis (HFMEA) to Reduce Venous Thromboembolism after Joint Replacement Surgery

靜脈血栓栓塞為術後嚴重併發症之一，本單位於2022年1-12月發生5件，雖未造成死亡，仍具高度風險，促使團隊展開品質改善。自2023年1月至2024年12月，導入醫療照護失效模式與效應分析（healthcare failure mode and effects analysis，HFMEA），檢視流程並辨識10項潛在失效原因，據以制定改善措施，包括建立靜脈血栓栓塞預防標準作業流程、導入臨床決策支持系統及規劃教育訓練。介入後，風險優先數由148分降至40分，改善率72.9%，潛在失效模式亦降為零。統計分析顯示，靜脈血栓栓塞發生率由介入前0.77%（5／652）降至介入後0%（0／696），差異達統計顯著（p = 0.026），絕對風險差0.77%（95%CI = [-1.44，.-0.1]），益一需治數為130。綜合而言，本改善計畫透過HFMEA系統性分析與多元介入，有效降低潛在風險並顯著改善VTE發生率，強化病人安全與醫療品質。

Venous thromboembolism (VTE) is a serious postoperative complication. In 2022, five VTE cases occurred in our institution, prompting a quality improvement project. From January 2023 to December 2024, Healthcare Failure Mode and Effect Analysis (HFMEA) was applied to review care processes, identifying 10 potential failure modes. Interventions included establishing a standardized VTE prevention protocol, integrating a clinical decision support system, and providing staff training. After implementation, the Hazard Score decreased from 148 to 40 (72.9% improvement), and all potential failure modes were eliminated. Statistically, VTE incidence declined from 0.77% (5/652) before intervention to 0% (0/696) after intervention, with a significant difference by Fisher’s exact test (p = 0.026). The absolute risk difference was 0.77%(95%CI = [-1.44, .-0.1]), corresponding to a Number Needed to Treat of 130. In summary, this project demonstrated that HFMEA combined with multifaceted interventions effectively reduced potential risks and significantly improved VTE outcomes, enhancing patient safety and overall care quality.