Quality Management Center, Cathay General Hospital, Taipei, Taiwan.
J Med Syst. 2012 Jun;36(3):1543-51. doi: 10.1007/s10916-010-9616-7. Epub 2010 Nov 11.
To evaluate risk and vulnerability in the chemotherapy process using a proactive risk analysis method. Healthcare failure mode and effect analysis (HFMEA) was adopted to identify potential chemotherapy process failures. A multidisciplinary team is formed to identify, evaluate, and prioritize potential failure modes based on a chemotherapy process flowchart. Subsequently, a decision tree is used to locate potential failure modes requiring urgent improvement. Finally, some recommended actions are generated and executed to eliminate possible risks. A total of 11 failure modes were identified with high hazard scores in both inpatient and outpatient processes. Computerized physician order entry was adopted to eliminate potential risks in chemotherapy processes. Chemotherapy prescription errors significantly decreased from 3.34% to 0.40%. Chemotherapy is regarded as a high-risk process. Multiple errors can occur during ordering, preparing, compounding, dispensing, and administering medications. Subsequently, these can lead to serious consequences. HFMEA is a useful tool to evaluate potential risk in healthcare processes.
采用主动风险分析方法评估化疗过程中的风险和脆弱性。医疗保健失效模式和影响分析（HFMEA）用于识别潜在的化疗过程失败。组建多学科团队，根据化疗流程图识别、评估和优先考虑潜在的失效模式。然后，使用决策树定位需要紧急改进的潜在失效模式。最后，生成并执行一些建议措施，以消除潜在风险。在住院和门诊过程中，共确定了 11 种失效模式，其危险评分均较高。采用计算机化医嘱录入以消除化疗过程中的潜在风险。化疗处方错误从 3.34%显著下降至 0.40%。化疗被认为是一个高风险的过程。在医嘱、准备、配制、配药和给药过程中都可能出现多种错误，进而可能导致严重后果。HFMEA 是评估医疗保健过程中潜在风险的有用工具。
