應用「醫療照護失效模式與效應分析」HFMEA評估核醫造影給藥安全並改善作業流程以提升整體醫療品質
Journal
核子醫學暨分子影像雜誌
Journal Volume
29
Journal Issue
3
Pages
105-125
Date Issued
2016
Author(s)
YEN-WEN WU
Abstract
Background: Healthcare failure mode and effect analysis (HFMEA) is a proactive tool used to analyze risks, identify potential failures before they occur and prioritize preventive measures. The aims of this study were to evaluate the frequency, type, preventability, as well as potential and actual severity of radiopharmaceutical administration errors in a nuclear department in a tertiary medical center, to examine the hazards associated with the process and identify where improvements are needed. Methods: The multidisciplinary teams of nuclear physicians, radiologists, clinical laboratory technologists and nurses were trained to analyze the drug-delivery process, to identify possible causes of failures and their potential effects, to calculate a risk priority number (RPN) for each failure. Probability of occurrence was classified using a six-point scale. Severity was defined according to the HFMEA Severity Scale. The study was to identify higher-priority potential failure modes as defined by RPNs and to plan changes in clinical practice in order to reduce the risk of patient harm and improve safety in the process. Results: In all, radiopharmaceutical maladministration identified 31 failure modes, 40 associated causes and effects were identified. Most errors were preventable and the adverse events to diagnostic radiopharmaceuticals had no immediate adverse effect, and no or little effect on clinical outcome. Seven failure causes were identified to require high-priority improvement; 7 failure modes with high risk should be re-evaluated. The introduction of new activities in the revised process allowed reducing the number of high-risk failure modes from 31 to 21, and resulted in a significant reduction in severity scores. Conclusions: HFMEA is a valid proactive risk assessment tool to aid multidisciplinary teams in understanding the care processes and identifying errors that may occur, prioritizing remedial interventions and possibly enhancing the safety of radiopharmaceutical administrations.
SDGs
Type
journal article