The U.S. Institute of Medicine estimates that there are 98,000 people died yearly from medical errors; approximate 20,000 people died from medical adverse events annually was estimated in Taiwan. All these reports indicate that the medical errors have great impact on patient safety. The hemodialysis population in Taiwan keeps increasing these years, and this means more attention should be paid to patient safety with the growing hemodialysis population. In 2005, Taiwan Joint Commission on Hospital Accreditation sets six goals for patient safety, general guidelines for healthcare facilities, and relative regulations are mostly on standard devices. This study tries to provide more possible root causes about patient safety at a hemodialysis center.
Root cause analysis (RCA) has been greatly used in patient safety because latent factors can be determined by RCA. RCA was simulated in this study at a hemodialysis center. Firstly, a series of formal questions, developed by the U.S. Department of Veteran Affairs, were used to examine the current situation. The questions used are composed of six dimensions. Then, cause-effect-diagram was used to locate latent causes, and finally identified four dimensions. Research results are mainly summarized as human resource management issues, including two root causes of inadequate professional training and overwork. Adjusted job assignment and job content are also suggested in this study.
| Identifer | oai:union.ndltd.org:NSYSU/oai:NSYSU:etd-1216105-125221 |
| Date | 16 December 2005 |
| Creators | Chu, Fen-Yao |
| Contributors | Kim-Jean Chow, Huei-Mei Liang, Hsueh-Wen Chang |
| Publisher | NSYSU |
| Source Sets | NSYSU Electronic Thesis and Dissertation Archive |
| Language | Cholon |
| Detected Language | English |
| Type | text |
| Format | application/pdf |
| Source | http://etd.lib.nsysu.edu.tw/ETD-db/ETD-search/view_etd?URN=etd-1216105-125221 |
| Rights | unrestricted, Copyright information available at source archive |
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