| Summary: | 碩士 === 國立清華大學 === 工業工程與工程管理學系 === 104 === With the importance of patient safety increasing, improving patient safety can enhance the medical quality. The goal of the Taiwan Patient Safety Reporting System (TPR System) is to promote the patient safety and the quality of medical service by knowledge sharing between hospital institutions. The purpose of this study is to make good use of the data gathered from the TPR system by identifying the root causes of the
adverse events precisely and correctly.
The study consists of two stages. The first stage is to evaluate the original TPR system by comparing the results of the Root Cause Analysis (RCA) and the TPR system itself. We used 18 adverse drug events as our materials and recruited 4 experts to analyze those events by using RCA. Thirty nurses were recruited to report those events to the TPR system. With systematical approach, we applied the HFACS model to analyze these two results. The study indicated that the sum of the causal factors and the number of causal factors from all layers in HFACS model are less than the results from the RCA. It implied that the original TPR system cannot offer useful and effective information for causal analysis. The second stage was based on the conclusions in the previous stage. We established an improved TPR system which was added the core thinking of the RCA and guided the user to consider the adverse events in systematic approach. We recruited another 30 nurses to report those 18 events by the new system and used the same way to evaluate the new system. Comparing the original and improved TPR system, the results showed that the new system can obtain more causal factors; moreover, the number of causal factors in the second, third layer in HFACS model are significantly much more than the original system. After the improvement, the new system may help user to reconsider the adverse event completely and the results from the new system is more closed to the RCA. It suggested that the new TPR system can enhance the utility of the
data which the system obtained and discover the root causes more easily.
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