Title page for etd-1216105-125221


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URN etd-1216105-125221
Author Fen-Yao Chu
Author's Email Address m924070003@student.nsysu.edu.tw
Statistics This thesis had been viewed 4651 times. Download 4176 times.
Department Institute of Health Care Management
Year 2005
Semester 1
Degree Master
Type of Document
Language zh-TW.Big5 Chinese
Title Quality Improvement on Patient Safety at a HEmodialysis Center- Using Root Cause Analysis
Date of Defense 2005-11-10
Page Count 71
Keyword
  • Root cause analysis
  • patient safety
  • hemodialysis
  • 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.
    Advisory Committee
  • Hsueh-Wen Chang - chair
  • Huei-Mei Liang - co-chair
  • Kim-Jean Chow - advisor
  • Files
  • etd-1216105-125221.pdf
  • indicate access worldwide
    Date of Submission 2005-12-16

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