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RCA FMEA

QC tools. Iceberg modelSwiss cheese modelMigration model ???? (???????)SRK model skill, rule, knowledgeRCA root cause analysisFMEA, HFMEA (health) failure mode

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RCA FMEA

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    1. RCA & FMEA ???? ?????? ??? ??

    3. RCA ??: ??????vincristine?????spinal canal The boy died a few days later ?????:????

    4. 10 yr, boy, lymphoma, s/p C/T, in good recovery This time, the last course C/T IV vincristine by oncologist IT methotrexate (MTX) by anesthetist at OR under sedation AM 8:00, ? C/T OPD Starbarks: milk, some cakes Delay the C/T due to NPO (X) ? PAD Cancer ward full ? infection ward to wait until PM

    5. Oncologist prescribes the 2 drugs, then take a leave PM PM: Drugs sent to ward boy sent to OR with 2 drugs (in theory, vincristine should be given IV in ward.) Anesthetist persuades the boy not to receive sedation to go home earlier after the treatment, boy agrees, anesthetists talks with oncologist. ‘Vincristine is not given in the ward.” Oncologist asks a help from anesthetist. “it is simple, just inject into the boy” Set spinal needle ? MTX injection ? vincristine injection Boy cries for pain, anesthetist holds for a few seconds, then rapidly injects. …………….. …………….. The boy dies a few days later with suffering.

    7. What’s wrong? NPO ? nursing education Infection ward, not cancer ward (not familiar with cancer drugs) Oncologist take a leave (no substitute) IV vincristine is not given in the ward. (no SOP to give drug) (vincristine & MTX) ? OR (in theory, vincristine should not be taken to OR.) Talk between anesthetist & oncologist (not effective communication) …………… …………… Anesthetist injects vincristine into spinal canal!

    8. To err is human. To forgive is divine. No body has to be blamed. But: No mistakes can be tolerated by ……... System should be designed perfectly.

    9. RCA (root cause analysis) ???? ???? human action ? teaching, ???? administration ? SOP Physical ? bump in the road, ???? nature ? ?(??)?(?)??

    12. RCA ????,????? ????,????? ????,????? ?????,???? (ameba level) ? trial and error ?????,????? ????????? ????,???? ????????? ????:????,????? ???:????????

    13. ?? ???????, ????????

    14. RCA (root cause analysis) ???? ???? ????? (?????) ?:???? ???????? (H)FMEA (health failure mode & effect analysis) ???? ??? ????????? ?:???,????

    15. FEMA ??????? ???????? ?????????? (????) failure mode ????????? ????????? ??????? ???

    16. ???????? ??? ??(input)??? ???? ??????? ??????????? ??????

    17. More steps, more errors.

    18. ???????????? ???? ???? ??????? ????????

    19. HFMEA ?????

    20. HFMEA ????

    21. HFMEA hazard scoring matrix

    22. HFMEA action Eliminate ? ???? Control ? ????,???? Mitigate ? ???????

    23. ??????? Standardization Simplification Backup (optimal redundancy) Automation Fail-safe design (????) Documentation (Talk is cheap.)

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