利用根本原因分析(Root Cause Analysis,RCA)改善化療藥物外滲事件

Translated title of the contribution: Using Root Cause Analysis to Improve Chemotherapy Extravasation Adverse Event

王 新芳(Hsin-Fang Wang), 黃 秀英(Hsiu-Ying Huang), 祝 孔聖(Kung-Sheng Chu), 王 傳育(Chuan-Yu Wang), 馬 君(Chun Mah), 王 良順(Liang-Shun Wang), 彭汪 嘉康(Jacqueline Whang-Peng)

Research output: Contribution to journalArticle

Abstract

Purpose: The aim of this article was to describe the use of root cause analysis (RCA) for identifying the possible causes of an adverse event involved vesicant extravasation injury from a central venous Port-A catheter, a rare reported, and provide attention & prevention.Methods: As a serious and sentinel event, an investigation team was established. Key participants were identified and an RCA was implemented systematically with a trained facilitator guiding each analysis step. Chronological narratives were tabulated in a timeline sheet. Why tree & Barrier analysis were used to determine the root factors of this event.Results: Three root causes of the extravasation event were identified, which included 1. Port-A needle was not qualify, 2. Nurse was not alert of the potential of extravasation of the patients first time receiving chemotherapy, 3. Reporting of adverse event was slow. Based on the analysis, we implemented action plan to ensure safety in administering chemotherapy. After the improvement measures, we have not had similar event recurred.Discussion: RCA is a useful tool to identify the causes of an adverse event. Subsequent measures can target the causes to prevent or reduce future occurrence of the event. However, implementing the desired changes can be a challenge in which the measure required negotiation of changes outside of our institution.
Original languageTraditional Chinese
Pages (from-to)50-64
Number of pages15
Journal醫療品質
Volume5
Issue number1
Publication statusPublished - 2013

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Root Cause Analysis
Drug Therapy
Vascular Access Devices
Central Venous Catheters
Irritants
Negotiating
Needles
Nurses
Safety
Wounds and Injuries

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王新芳(Hsin-Fang W, 黃秀英(Hsiu-Ying H, 祝孔聖(Kung-Sheng C, 王傳育(Chuan-Yu W, 馬君(Chun M, 王良順(Liang-Shun W, & 彭汪嘉康(Jacqueline W-P (2013). 利用根本原因分析(Root Cause Analysis,RCA)改善化療藥物外滲事件. 醫療品質, 5(1), 50-64.

利用根本原因分析(Root Cause Analysis,RCA)改善化療藥物外滲事件. / 王新芳(Hsin-Fang Wang); 黃秀英(Hsiu-Ying Huang); 祝孔聖(Kung-Sheng Chu); 王傳育(Chuan-Yu Wang); 馬君(Chun Mah); 王良順(Liang-Shun Wang); 彭汪嘉康(Jacqueline Whang-Peng).

In: 醫療品質, Vol. 5, No. 1, 2013, p. 50-64.

Research output: Contribution to journalArticle

王新芳(Hsin-FangW, 黃秀英(Hsiu-YingH, 祝孔聖(Kung-ShengC, 王傳育(Chuan-YuW, 馬君(ChunM, 王良順(Liang-ShunW & 彭汪嘉康(JacquelineW-P 2013, '利用根本原因分析(Root Cause Analysis,RCA)改善化療藥物外滲事件', 醫療品質, vol. 5, no. 1, pp. 50-64.
王新芳(Hsin-FangW, 黃秀英(Hsiu-YingH, 祝孔聖(Kung-ShengC, 王傳育(Chuan-YuW, 馬君(ChunM, 王良順(Liang-ShunW et al. 利用根本原因分析(Root Cause Analysis,RCA)改善化療藥物外滲事件. 醫療品質. 2013;5(1):50-64.
王新芳(Hsin-Fang Wang) ; 黃秀英(Hsiu-Ying Huang) ; 祝孔聖(Kung-Sheng Chu) ; 王傳育(Chuan-Yu Wang) ; 馬君(Chun Mah) ; 王良順(Liang-Shun Wang) ; 彭汪嘉康(Jacqueline Whang-Peng). / 利用根本原因分析(Root Cause Analysis,RCA)改善化療藥物外滲事件. In: 醫療品質. 2013 ; Vol. 5, No. 1. pp. 50-64.
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title = "利用根本原因分析(Root Cause Analysis,RCA)改善化療藥物外滲事件",
abstract = "目的:本文描述一件癌症化療時發生Port-A靜脈導管外滲,造成醫療不良事件,運用RCA找出根本原因與改善方案,提供醫護人員注意與防範。材料:成立Port-A化療外滲RCA調查小組,使用「時間序列表」、「改變因素」檢視化療標準流程與實際執行之差異,列出前端因子,依臨床實證進行「原因樹」、「屏障分析」找出根本原因,並建立「改善計畫」。結果:確立3個根本原因;1. Port-A安全角針規格不符,引用錯誤。2. 護理師對第一次化療病人之反應警覺性不夠。3. 未及時通報異常,錯失急救傷害時機。因此修訂化療給藥流程及落實執行。討論:RCA確為院內醫療異常事件根本原因分析檢討改善有效之工具,然對規格不符之醫材與院外廠商協商修正,卻是一項挑戰。",
keywords = "根本原因分析, Port-A導管化療外滲, Root Cause Analysis, Port-A Catheter Extravasation",
author = "王, {新芳(Hsin-Fang Wang)} and 黃, {秀英(Hsiu-Ying Huang)} and 祝, {孔聖(Kung-Sheng Chu)} and 王, {傳育(Chuan-Yu Wang)} and 馬, {君(Chun Mah)} and 王, {良順(Liang-Shun Wang)} and 彭汪, {嘉康(Jacqueline Whang-Peng)}",
year = "2013",
language = "繁體中文",
volume = "5",
pages = "50--64",
journal = "醫療品質",
publisher = "台灣醫療品質協會",
number = "1",

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TY - JOUR

T1 - 利用根本原因分析(Root Cause Analysis,RCA)改善化療藥物外滲事件

AU - 王, 新芳(Hsin-Fang Wang)

AU - 黃, 秀英(Hsiu-Ying Huang)

AU - 祝, 孔聖(Kung-Sheng Chu)

AU - 王, 傳育(Chuan-Yu Wang)

AU - 馬, 君(Chun Mah)

AU - 王, 良順(Liang-Shun Wang)

AU - 彭汪, 嘉康(Jacqueline Whang-Peng)

PY - 2013

Y1 - 2013

N2 - 目的:本文描述一件癌症化療時發生Port-A靜脈導管外滲,造成醫療不良事件,運用RCA找出根本原因與改善方案,提供醫護人員注意與防範。材料:成立Port-A化療外滲RCA調查小組,使用「時間序列表」、「改變因素」檢視化療標準流程與實際執行之差異,列出前端因子,依臨床實證進行「原因樹」、「屏障分析」找出根本原因,並建立「改善計畫」。結果:確立3個根本原因;1. Port-A安全角針規格不符,引用錯誤。2. 護理師對第一次化療病人之反應警覺性不夠。3. 未及時通報異常,錯失急救傷害時機。因此修訂化療給藥流程及落實執行。討論:RCA確為院內醫療異常事件根本原因分析檢討改善有效之工具,然對規格不符之醫材與院外廠商協商修正,卻是一項挑戰。

AB - 目的:本文描述一件癌症化療時發生Port-A靜脈導管外滲,造成醫療不良事件,運用RCA找出根本原因與改善方案,提供醫護人員注意與防範。材料:成立Port-A化療外滲RCA調查小組,使用「時間序列表」、「改變因素」檢視化療標準流程與實際執行之差異,列出前端因子,依臨床實證進行「原因樹」、「屏障分析」找出根本原因,並建立「改善計畫」。結果:確立3個根本原因;1. Port-A安全角針規格不符,引用錯誤。2. 護理師對第一次化療病人之反應警覺性不夠。3. 未及時通報異常,錯失急救傷害時機。因此修訂化療給藥流程及落實執行。討論:RCA確為院內醫療異常事件根本原因分析檢討改善有效之工具,然對規格不符之醫材與院外廠商協商修正,卻是一項挑戰。

KW - 根本原因分析

KW - Port-A導管化療外滲

KW - Root Cause Analysis

KW - Port-A Catheter Extravasation

M3 - 文章

VL - 5

SP - 50

EP - 64

JO - 醫療品質

JF - 醫療品質

IS - 1

ER -