Chuang Ching-Hui, Chuang Sheu-Wen
School of Medicine & Public Health, University of Newcastle, Australia.
Hu Li Za Zhi. 2009 Aug;56(4):62-70.
Medical institutions are increasingly concerned about ensuring the safety of patients under their care. Failure mode and effect analysis (FMEA) is a qualitative approach based on a proactive process. Strongly promoted by the Joint Commission Accredited of Health Organization (JCAHO) since 2002, FMEA has since been adopted and widely practiced in healthcare organizations to assess and analyze clinical error events. FMEA has proven to be an effective method of minimizing errors in both manufacturing and healthcare industries. It predicts failure points in systems and allows an organization to address proactively the causes of problems and prioritize improvement strategies. The application of FMEA in chemotherapy at our department identified three main failure points: (1) inappropriate chemotherapy standard operating procedures (SOPs), (2) communication barriers, and (3) insufficient training of nurses. The application of FMEA in chemotherapy is expected to enhance the sensitivity and proactive abilities of healthcare practitioners during potentially risky situations as well as to improve levels of patient care safety.
医疗机构越来越关注确保其照护下患者的安全。失效模式与效应分析（FMEA）是一种基于主动过程的定性方法。自2002年以来，在卫生组织联合委员会认可（JCAHO）的大力推动下，FMEA此后已在医疗机构中被采用并广泛应用于评估和分析临床差错事件。FMEA已被证明是在制造业和医疗行业中最大限度减少差错的有效方法。它能预测系统中的故障点，并使组织能够积极解决问题的原因并对改进策略进行优先级排序。FMEA在我们科室化疗中的应用确定了三个主要故障点：（1）化疗标准操作程序（SOP）不当，（2）沟通障碍，以及（3）护士培训不足。FMEA在化疗中的应用有望提高医护人员在潜在风险情况下的敏感性和主动能力，并提高患者护理安全水平。
