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博碩士論文 etd-1216105-125221 詳細資訊
Title page for etd-1216105-125221
論文名稱
Title
探討血液透析之病患安全品質-使用根本原因分析
Quality Improvement on Patient Safety at a HEmodialysis Center- Using Root Cause Analysis
系所名稱
Department
畢業學年期
Year, semester
語文別
Language
學位類別
Degree
頁數
Number of pages
71
研究生
Author
指導教授
Advisor
召集委員
Convenor
口試委員
Advisory Committee
口試日期
Date of Exam
2005-11-10
繳交日期
Date of Submission
2005-12-16
關鍵字
Keywords
血液透析、根本原因分析、病人安全
Root cause analysis, patient safety, hemodialysis
統計
Statistics
本論文已被瀏覽 5689 次,被下載 5611
The thesis/dissertation has been browsed 5689 times, has been downloaded 5611 times.
中文摘要
意外的發生常起因於一連串的關鍵事件。美國1999年發表的研究報告估計,每年美國因醫療錯誤死亡的人數多達98,000人;醫策會估計台灣每年約有6,000至20,000人因醫療不良事件死亡。這些數據說明不良事件對病人安全的重大影響。
台灣自1997年至2004年間,血液透析人口約成長一倍。如此眾多的透析人口,相關的病人安全研究卻為少數,大部份研究在用藥安全方面。另外,透析治療的複雜性,使病人安全研究更加困難。
根本原因分析(Root Cause Analysis,RCA)可以找出事件的遠端因子,因此常作為病人安全研究的工具。本研究模擬RCA,探討一地區醫院附設血液透析中心之病人安全議題。於眾多RCA做法中,本研究採用美國退伍軍人局(U.S. Department of Veteran Affairs,VA)發展的事件分類問題(共分為六個構面)以評估個案的病人安全狀況,並使用魚骨圖進一步探討可能導致異常事件的遠端因子。研究結果顯示,於六個構面中,有四個構面含潛在危險因子。依據各個遠端因子進行深入探討。本研究發現人力資源管理為個案首要議題,並建議個案進行工作分配和工作內容調整。
Abstract
The U.S. Institute of Medicine estimates that there are 98,000 people died yearly from medical errors; approximate 20,000 people died from medical adverse events annually was estimated in Taiwan. All these reports indicate that the medical errors have great impact on patient safety. The hemodialysis population in Taiwan keeps increasing these years, and this means more attention should be paid to patient safety with the growing hemodialysis population. In 2005, Taiwan Joint Commission on Hospital Accreditation sets six goals for patient safety, general guidelines for healthcare facilities, and relative regulations are mostly on standard devices. This study tries to provide more possible root causes about patient safety at a hemodialysis center.
Root cause analysis (RCA) has been greatly used in patient safety because latent factors can be determined by RCA. RCA was simulated in this study at a hemodialysis center. Firstly, a series of formal questions, developed by the U.S. Department of Veteran Affairs, were used to examine the current situation. The questions used are composed of six dimensions. Then, cause-effect-diagram was used to locate latent causes, and finally identified four dimensions. Research results are mainly summarized as human resource management issues, including two root causes of inadequate professional training and overwork. Adjusted job assignment and job content are also suggested in this study.
目次 Table of Contents
目錄
誌謝 I
摘要 II
ABSTRACT III
目錄 IV
表目錄 VI
圖目錄 VII
第一章 緒論 1
第一節 研究背景與動機 3
第二節 研究流程與目的 6
第二章 文獻探討 8
第一節 病人安全 8
第二節 血液透析與病人安全 12
第三節 根本原因分析 15
第三章 研究方法 21
第一節 研究架構 21
第二節 研究假設 22
第四章 個案實證分析 23
第一節 研究個案介紹 23
第二節 使用RCA分析個案現況 25
第三節 使用RCA確認根本原因 32
第五章 研究結論與建議 36
第一節 結論 36
第二節 建議 37
第三節 研究限制及未來研究方向 38
參考文獻 40
附錄 43
附錄A VA事件分類法六構面問卷原文 43
附錄B 血液透析與病人安全相關流程 51




表目錄
表2-1 執業中西醫之醫療糾紛發生率比較 9
表2-2 病人安全研究常見名詞之定義 10
表2-3 血液透析用水內容物的可能臨床反應 13
表4-1 個案之異常事件等級歸納 24
表4-2 人為因素之溝通結果 26
表4-3 人為因素之訓練結果 27
表4-4 人為因素之疲倦結果 27
表4-5 環境及設備結果 29
表4-6 規則/政策/程序結果 30
表4-7 控管措施結果 30
表4-8 利用RCA找出之爭論點 32

圖目錄
圖1-1 台灣定期透析治療人數成長趨勢 4
圖1-2 台灣定期透析門診申報費用成長趨勢 5
圖1-3 研究流程 7
圖2-1 醫療異常事件分類圖 11
圖2-2 錯誤、失敗,與不良事件之間的交互作用 11
圖2-3 透析安全 15
圖2-4 不同的系統監控方式與流程的關係 17
圖2-5 反覆詢問法圖例 19
圖2-6 事件分類法 20
圖3-1 研究架構 22
圖4-1 人為因素與非人為因素 31
圖4-2 魚骨圖 35
參考文獻 References
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二、 中文文獻
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