ارزيابي و مديريت ريسك باليني در فرآيند دارودهي بيماران بخش CCU به روش HFMEA

CLINICAL RISK ASSESING an‎d MANAGEMENT IN MEDICATION PROCESS OF CCU BY HFMEA

پيش زمينه و هدف امروزه خطاهاي دارويي به عنوان شايع ترين خطاي پزشكي چالشي مهم براي نظام هاي سلامت و تهديدي براي ايمني بيمار محسوب مي شود، اين پژوهش باهدف ارزيابي و مديريت ريسك باليني در فرآيند دارو دهي بيماران بستري در بخش CCU بيمارستان هاي آموزشي شهر مشهد با استفاده از فن HFMEA در سال 1396 انجام شد. مواد و روش كار پژوهش حاضر از نوع تركيبي (كيفي-كمي و توصيفي-مقطعي) مي باشد كه طي آن داده ها از طريق مشاهده مستقيم، بررسي اسناد و فن FGD به روش نمونه گيري مبتني بر هدف، گردآوري و مطابق دستورالعمل HFMEA نسبت به تحليل ريسك، علل ريشه اي خطاها و ارائه اقدامات اصلاحي اقدام گرديد. براي تعيين فرآيند اولويت دار از روش AHP فازي، براي طبقه بندي علل خطاها از مدل Eindhoven و تعيين اقدامات اصلاحي از روش توليد ايده (Idea Generation) استفاده شد. در پايان اثربخشي فرآيند مديريت ريسك مورد ارزيابي قرار گرفت. داده ها با استفاده از نرم افزار Excel به روش هاي آمار توصيفي تحليل گرديد. يافته ها درمجموع 50 حالت خطاي بالقوه در فرآيند 5 مرحله اي دارو دهي شناسايي كه 15 حالت آن به عنوان خطاهاي غيرقابل قبول مشخص گرديد، به طوري كه از مجموع علل ريشه اي شناسايي شده،62.7 درصد به عنوان خطاهاي نهفته و 37.3 درصد به عنوان خطاهاي آشكار طبقه بندي شد. در ارزيابي مجدد سطح ريسك، نسبت ريسك هاي غيرقابل قبول با لحاظ اقدامات اصلاحي، از 56.9 به 21.6 درصد كاهش مي يابد.

Background & Aim: Nowadays, medication errors as the most common medical error are among the most important health and safety issues for patient safety. The aim of this study was Assessing and Management of Clinical Risk in medication Process of CCU in Mashhad teaching hospitals by HFMEA Method. Materials & Methods: The present study is a combination (qualitative – quantitative, cross sectional -descriptive) method. Data was collected through direct observation, review of documents, FGD technique by Non-probabilistic sampling based on purpose and by HFMEA standard work-sheet to risk analysis, decision tree analysis, identifying the root causes of failure states and suggestion of Improvement measures. In this study Fuzzy AHP (Analytical hierarchy process) Technique for selecting Priority Process, the Eindhoven model (ECM) was used and the Idea Generation Method was used to suggestion Improvement measures. Finally, data was analyzed using Excel software by descriptive statistics. Results: A total of 50 failure states in the 5-step medication process were identified, so that failure states were identified as unacceptable risk.so that from the total root causes of erorrs were categorized based on the ECM model, 62.7% of latent errors and 37.3% of obvious errors and Improving measures were suggested., if these strategies are implemented, in the re-evaluated Controlled Risk The ratio of unacceptable risks will decrease from 56.9% to 21.6%. Conclusion: The essential medication process due to Medicinal errors in some cases instead of treatment may increased costs, injury and prolonged hospital stay. The HFMEA Method with preventive approach and the focusing of systems rather than individual errors, in order to identify and resolve increases the agreement on process and organizational weakness and can play an Effectiveness role in eliminate the root causes of errors, especially in the sensitive and complex of the CCU ward.