運用HFMEA降低心導管鞘管拔除出血合併症發生率

目的：鑒於本單位2019年8-12月心導管鞘管拔除造成出血合併症之比率高達4.03%，為預防動脈異常性大出血、休克等延長住院天數事件，故運用HFMEA的步驟與手法降低心導管鞘管拔除出血合併症發生率。方法：運用HFMEA分析出5個失效模式、失效原因，藉由建置鞘管移除的標準作業流程和評估表單，設計多媒體教育課程和製作專屬警示、提醒工具等具體改善措施，針對醫療照護流程中高風險因子建立防範機制，以有效維護並確保病人安全。結果：執行改善措施後，原5項潛在失效原因危害指數從12分降至3分，出血合併症由4.03%降為0%。結論：運用HFMEA不僅有效降低心導管鞘管拔除出血合併症發生率，提升醫療照護的準確性，亦彰顯出本團隊確實為病人安全與醫療福祉把關的實質效益。 Purpose: Between August and December 2019, the incidence of bleeding complications following arterial sheath removal after cardiac catheterization in a Medical Intensive Care Unit (MICU) reached 4.03%. Several cases resulted in massive arterial bleeding, hemorrhagic shock, and prolonged hospitalization. This study applied Healthcare Failure Mode and Effect Analysis (HFMEA)to systematically examine the arterial sheath removal process, identify high-risk failure modes and their underlying causes, and implement preventive strategies to reduce bleeding complications. Methods: Using the HFMEA framework, the arterial sheath removal care process was analyzed to identify five major failure modes and their associated causes. Based on the hazard scoring results, targeted improvement strategies were developed and implemented. These included establishment of a standardized operating procedure for arterial sheath removal, development of a dedicated assessment form, implementation of structured on-the-job training programs, and creation of visual warning and reminder tools to enhance adherence to safe care practices. Results: Following implementation of the improvement strategies, the hazard scores of the five identified failure causes decreased from 12 to 3. Bleeding complications related to arterial sheath removal were completely eliminated, with the incidence reduced from 4.03% to 0%. Conclusion: Application of HFMEA effectively improved the accuracy and consistency of arterial sheath removal care and strengthened interprofessional collaboration. These patient-centered interventions significantly reduced bleeding complications and contributed to improved patient safety and quality of care following cardiac catheterization.