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系統識別號 U0026-0812200910351031
論文名稱(中文) 病患安全風險因素之研究—以台灣大型醫院急診部門為例
論文名稱(英文) The Study on Risk Factors of Patient Safety -- An Empirical Study of the Emergency Departments of Large-Scaled Hospitals in Taiwan
校院名稱 成功大學
系所名稱(中) 高階管理碩士在職專班(EMBA)
系所名稱(英) Executive Master of Business Administration (EMBA)
學年度 91
學期 1
出版年 92
研究生(中文) 林宏榮
研究生(英文) Hung-Jung Lin
學號 r4789104
學位類別 碩士
語文別 中文
論文頁數 70頁
口試委員 口試委員-郭浩然
指導教授-張有恆
口試委員-蔡東峻
中文關鍵字 病患安全  醫療錯誤  SHEL模式  HELPS模式 
英文關鍵字 patient safety  SHEL model  HELPS model  medical errors 
學科別分類
中文摘要   1999年美國國家科學院的附屬醫學研究機構(Institute of Medicine)指出美國醫療錯誤的嚴重程度,震驚了美國社會。民國九十一年年底在台灣,連續發生北城醫院與崇愛診所給錯藥的事件,同樣引起台灣民眾對醫療錯誤的關切。

  台灣以系統性的角度探討醫療錯誤之研究仍是罕見,因此本研究選定以醫療錯誤與病患安全之發展為課題,引進航空業的人因工程理論模式,選擇台灣大型醫院急診部門病患安全之風險因素進行探討,以為醫界發展病患安全策略之參考。

  本研究採用人因工程的SHEL理論、加入病患因素之構面成合適醫療業新的HELPS研究模式。本研究採兩階段研究方式、以專家問卷進行調查。第一階段風險因素選取,係參考國內外文獻與參酌專家意見而成,共選出四十個因素。第一階段從六個構面與四十個因素中,使用模糊德菲法統計,依專家意見評選出二十個重要之風險因素,修改成新的研究架構,再進行第二階段專家問卷,以模糊層級分析法進行構面與因素之兩兩相比、決定準則權重,最後排出各構面與各風險因素的優先順序。

  構面權重之優先序為急診核心醫護人員能力、醫療人員與病患及家屬互動、醫療人員互動、醫療人員與軟體系統互動、醫療人員與硬體設備互動、醫療人員與環境互動。所有因素對整體構面排行中以急診醫師專科知識技能不足為最重要影響病患安全之因素,其次為醫師與病患及家屬溝通不良,第三是急診主治醫師人力不足,第四是醫護人員醫療疏失風險認知不足,第五是排班型態的不合理。

  因此急診專科醫師人力的質與量是當務之急,因為以HELPS模式來看,Liveware(醫師)是這個系統的核心,沒有優秀而充分的的主治醫師人力將是影響病患安全的重大風險。醫師與病患及家屬溝通不良也使專家所重視之風險因素。

  政府官員在對錯誤報告系統的評價在所有風險因素排名第一,可能係反映衛生署規劃中醫療錯誤報告系統之政策,才會與其他兩組產生落差。

  本研究建立HELPS模式,來進行病患安全的研究,專家皆認為新增之醫療人員與病患及家屬互動構面十分重要,證實HELPS模式可以適合醫療系統的分析研究,建議後續研究者繼續使用此模式,以進一步研究HELPS模式的優缺點。另外本研究從產、官、學三個角度去衡量急診部門病患安全之風險因素,為國內關於病患安全之首次實證研究,其結果應可供醫界發展病患安全參考之價值。
英文摘要   The Report of the Institute of Medicine “To Err is Human” in 1999 pointed out the serious problem of medical errors. The American society was shocked. In 2002, serial events of medication errors in Taiwan made people concerned for patient safety, too.

  There had been few studies in Taiwan addressing to medical errors from the point of systems. Our study focused on the risk factors of patient safety in the emergency department of large-scaled hospitals in Taiwan, with application of theories of human factor engineering in aviation, and made suggestions on strategies to improve patient safety.

  This research incorporated the “Patient” dimension into the SHEL model and constructed a new “HELPS” model for healthcare. The study had proceeded in two stages. In the first stage, twenty factors were chosen from original forty factors according to survey of the experts. We used Fuzzy Delphi method for statistical analysis. In the second stage, experts underwent paired comparisons between dimensions and factors to determine the relative weights. Fuzzy Analytical Hierarchy Process method was used for statistical analysis.

  The priorities of dimensions in the descending order are: the ability of the core doctor-nurse team, the interaction between medical personnel and patients, the interaction between medical personnel, the interaction between medical personnel and software, the interaction between medical personnel and hardware and the interaction between medical personnel and environment.

  Among the 20 risk factors, deficiency of profession knowledge and skills of emergency physicians ranked the first. Poor communication between doctors and patients ranked the second. The third important risk factor was deficiency of emergency staff physicians. The fourth risk important factor was inadequate attitude toward medical errors. The fifth risk important factor was a bad shift pattern.

  It is urgent to increase qualified emergency physicians. From the point of “HELPS” model, emergency physicians as the center liveware play an important role. Deficiency of competent emergency physicians would put a great risk on patient safety. Poor communication between doctors and patients is important, too. The importance of reporting systems on medical errors was emphasized obviously by the officials. It reflected the ongoing processes of planning reporting systems by the officials.

  This study constructed a new HELPS model for patient safety. It was proved to be useful and suitable for healthcare. Subsequent studies using this model is recommended. This is the first empirical study on patient safety in Taiwan and the study results could provide advise in developing patient safety.
論文目次 致謝 I
摘要 II
目錄 VI
圖目錄 VII
表目錄 VIII
第一章 緒論 1
  1.1 研究背景與動機 1
  1.2 研究目的 2
  1.3 研究範圍與限制 2
  1.4 研究內容與方法 3
  1.5 研究流程 4
第二章 文獻探討 6
  2.1 醫療錯誤及病患安全 6
  2.2 飛安事故與人因工程理論 11
  2.3 風險管理 18
  2.4 飛航安全理論在病患安全之應用 19
  2.5 小結 24
第三章 研究方法 27
  3.1 研究架構的建立 27
  3.2 風險因素的選取 29
  3.3 統計方法 34
第四章 實證分析 40
  4.1 第一階段病患安全之風險因素指標之篩選 40
  4.2 第二階段問卷與模糊層級分析法權重 48
第五章 結論與建議 59
  5.1 結論 59
  5.2 建議 61
參考文獻 64
附 錄 71
參考文獻 一、中文部分
1. 王河清,鄭博文,2001。運用層級分析法探討引起醫療糾紛的因素,雲林科技大學工管所碩士論文。

2. 交通部民用航空局,2001。航空安全–人為因素探討及案例分析。

3. 何曉琪,2001。醫療錯誤之國際發展與研究取向之優劣分析–美國、澳洲、英國及台灣之實證分析,台灣大學衛生政策與管理研究所碩士論文。

4. 宋文娟,2001。一種質量並重的研究法—德菲法在醫務管理學研究領域之應用,醫務管理期刊,第二卷第二期,11-20。

5. 李昭蒂,2000。航空公司安全績效評估之研究,成功大學交管所碩士論文。

6. 林惠珍,1994。處方簽內容問題分析之實證研究,國立陽明醫學院醫務管理研究所碩士論文。

7. 紀政良,1998。某區域教學醫院門診處方之評估,私立臺北醫學院藥學研究所碩士論文。

8. 許育彰,2000。健保門診非成癮性止痛藥處方型態分析及處方問題探討,國立台灣大學衛生政策與管理研究所碩士論文。

9. 粘淑惠,1995。模糊層級分析法應用在交通運輸計畫評估之研究,高雄工學院管理科學研究所碩士論文。

10. 陳嚥如,2000。航空公司獲利力對飛安績效影響之研究,成功大學交管所碩士論文。

11. 張有恆,2002。航空事業風險管理之研究,國科會專題研究計畫申請書。

12. 葉牧青,1989。AHP層級結構設定問題之探討,國立交通大學管科所碩士論文。

13. 劉厚彭,2000。國內航空公司組織文化與飛安績效之研究,成功大學工管所碩士論文。

14. 蔡明志,2000。風險管理在大眾運輸安全管理管制課題之發展應用,運輸計畫季刊,第二九卷第一期,181-211。

15. 鄧淵源,曾國雄,1989a。層級分析法(AHP)的內涵特性與應用(上),中國統計學報,第二七卷第六期,5-22。

16. 鄧淵源,曾國雄,1989b。層級分析法(AHP)的內涵特性與應用(下),中國統計學報,第二七卷第七期,1-20。

17. 盧昭文,2000。醫師遭遇醫療糾紛之經驗與其認知、態度對醫師行為影響之研究--以大台北地區為例,國立台灣大學醫療機構管理研究所碩士論文。



二、英文部分

1. Adams, J. G. and Bohan, J., 2000. System contributions to error, Academic Emergency Journal, 7(11): 1189-1193.

2. Azis, I. J. 1990. Analytic Hierarchy Process in the Benefit-Cost-Framework: A Post-Evaluation of the Trans-Sumatra Highway Project , European Journal of Operational Research, 48: 38-48.

3. Barach, P. and S. D. Small, 2000. Reporting on medical mishaps: lessons from non-medical near miss reporting system, British Medical Journal, 320: 759-763.

4. Beckman, H.B. et al., 1994. The doctor-patient relationship and malpractice-lessons from plaintiff deposition, Archives of Internal Medicine, 154: 1365-1370.

5. Biros, M. H., J. G. Adams and R. L. Adams, 2000. Errors in emergency medicine. Academic Emergency Journal, 7(11): 1173-1174.

6. Bogner, M. S. 1994. Human error in medicine, Hillsdale: Lawrence Erlbaum Associates, Inc.

7. Brasel, K. J., P. M. Layde, P. M. and S. Hargarten, 2000. Evaluation of error in medicine: application of a public health model, Academic Emergency Journal, 7(11): 1298-1302.

8. Brennan, T. A., L. L. Leape, N. M. Laird et al., 1991. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I, New England Journal of Medicine, 324: 370-376.

9. Cohen, M.R., J. Senders and N.M. Davis, 1994. FMEA: a novel approach to avoid dangerous medication errors and accidents. Hospital Pharmacy, 29:319-324.

10. Cook, R., D. Woods and C. Miller, 1998. A Tale of Two Stories: Contrasting Views of Patient Safety, Chicago: National Patient Safety Foundation.

11. DeRosier, J., J. Stalhandske, J. P. Bagian et al., 2002. Using health care failure mode and effect analysis: the VA National Center for Patient Safety’s prospective risk analysis system, The Joint Commission Journal on Quality Improvement, 27(5): 248-26.

12. Handler, J. A., M. Gillam, A. B. Sanders et al., 2000. Defining, identifying, and measuring error in emergency medicine, Academic Emergency Journal, 7(11): 1183-1188.

13. Hawkins, F.H. 1993. Human Factors in Flight. 2nd ed., Aldershot: Avebury Technical.

14. Helmreich, R.J. 2000. On error management: lessons from aviation, British Medical Journal, 320: 781-785.

15. Helmreich, R.J. and D.M. Musson, 2000.Surgery as a team endeavor, Canadian Journal of Anesthesia, 47(5): 391-392.

16. Helmreich, R.J. and J.A. Wilhelm, 1991. Outcomes of crew resource management training, International Journal of Aviation Psychology, 1:287-300.

17. Helmreich, R.J. and D.M. Musson, 2000. The University of Texas Threat and Error Model, http://www.bmj.com/misc/bmj320.7237.781/sld001.htm.

18. Helmreich, R.J and A.C. Merrit, 2002. Culture at work in Aviation and Medicine: National, Organizational and Professional Influences, Aldershot, UK: Ashgate.

19. Henry, G.L. and D.J. Sullivan, 1997. Emergency Medicine Risk Management. Dollas, Texas: ACEP.

20. Joint Commission Resources, 2002. Failure Mode and Effects Analysis in Health Care, Oakbrook Terrace, IL: JCR.

21. Kohn, L. T., J. M. Corrigan and M. S. Donaldson (eds), 2000. To Err is Human: Building a Safer Health System. Institute of Medicine Report. Washington, DC: National Academy Press.

22. Lanning, J.A. and S. J. O’Connor, 1990. The health care quality some signpost, Hospital & Health Servicies Administration, 35(1): 39-45.

23. Layde, P.M., L. A. Maas, S. P. Teret et al., 2002. Patient safety should focus on medical injuries, Journal of American Medical Association, 287(15):1993-1997.

24. Leape, L.L., T.A. Brennan and N. Laird, 1991. The nature of adverse events in hospitalized patients. New England Journal of Medicine, 324(6): 377-384.

25. Lester, G.W. and S. G. Smith, 1993. Listening and lalking to patients: a remedy for malpractice suits, Western Journal of Medicine, 158: 268-272.

26. Leval, M. R. D. 1997. Human factors and surgical outcomes: a Cartesian dream, Lancet, 349: 723-725.

27. Levinson, W. 1997. Physician-patient communication : the relationship with malpractice claims among primary care physicians and surgeons, Journal of American Medical Association, 277(7): 553-559.

28. Lorazou, J., B. H. Pomeranz and P. N. Corey, 1998. Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies, Journal of American Medical Association, 279: 1200-1205.

29. Marabell, P. and L. W. Fitzsimmons, 1989. Understanding the powers of effective communication, Michigan Medicine, 88: 38-39.

30. McNutt, R. A., R. Abrams, and D. C. Aron, 2002. Patient safety efforts should focus on medical errors, Journal of American Medical Association, 287(15): 1997-2001.

31. National Patient Safety Foundation, 1999. “Agenda for Research and Development in Patient Safety”, http//www.ama.assn.org/med-sci/npsf/research/research.htm.

32. Nolan, T.W. 2000. System changes to improve patient safety, British Medical Journal, 320: 771-773.

33. Quality Interagency Coordination Task Force, 2000. Doing what counts for patient safety: Federal actions to reduce medical errors and their impact. Report to the President. Web site: www.quic.gov.

34. Reason, J.T. 1990. Human error. Cambridge, MA: Cambridge University Press.

35. Reason, J.T. 2000. Human error: models and management, British Medical Journal, 320: 768-770.

36. Sanders, M. and E.J. McCormick, 1987. Human Factors in Engineering, New York: McGraw Hill.

37. Sexton, J. B., E. J. Thomas and R. L. Helmreich, 2000. Error, stress and teamwork in medicine and aviation: cross sectional surveys, British Medical Journal, 320: 745-749.

38. Shapiro, R.S., D. E. Simpson, S. L. Lawrence, A. M. Talsky, K. A. Sobocinski and D. L. Schiedermayer, 1989. A survey of sued and nonsued physician and suing Patients, Archives of Internal Medicine, 149(10): 2190-2196.

39. Thomas, E. J., D. M. Studdert, J.P. Newhouse et al., 1999. Costs of Medical Injuries in Utah and Colorado, Inquiry, 36:255-264.

40. Thomas, E. J., D. M. Studdert, H. R. Burstin et al., 2000. Incidence and types of adverse events and negligent care in Utah and Corolado, Medical Care, 38: 250-260.

41. Valente, C., S. Taylor-Adams, and N. Stanhope, 1988. Framework for analyzing risk and safety in clinical medicine, British Medical Journal, 316: 1154-1157.

42. Vincent, C., R. Simon, K. Sutcliffe et al., 2000. Errors conference: executive summary, Academic Emergency Journal, 7(11): 1180-1182.

43. Wears, R. L. 2000. Beyond errors. Academic Emergency Journal, 7(11): 1175-1176.

44. Wears, R. L. and S.J. Perry, 2002. Human facotors and ergonomics in the Emergency Department, Annals of Emergency Medicine, 40(2): 206-212.

45. Weigner, M. B., C. Pantiskas and M. Wiklund, 1998. Incorporating human factors into the designs of medical devices, Journal of American Medical Association, 280(17): 1484.
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