Development of Medical HAZOP (hazard and operability studies)-An effective educational approach of medical safety management

虽然医院收集了一些事故报告，以改善患者安全管理，但很难消除所有医疗错误。教育方法是必不可少的，以提高病人的安全意识，特别是在住院医生。危害与可操作性研究（HAZOP）是20世纪70年代在化工等过程工业中发展起来的一种风险分析方法。HAZOP由三个步骤组成，以逐步的方式分析操作（称为工作分解结构），讨论错误的原因和后果，并将它们映射到风险矩阵中。HAZOP不同于FMEA（失效模式和影响分析）的一个主要特点是，按照指导语进行讨论，从而能够涵盖所有可能性。为了将HAZOP发展成为一种新的医疗安全管理教育方法，我们与住院医师、骨科医生、护士和共同医疗人员进行了大量的小组工作。住院医师的主题是气管插管、硬膜外插管和中心静脉置管；内窥镜下腰椎间盘手术和全髋关节置换术的主题会诊人员意外跌倒住院病人及处方管理的主题。大多数参与者评价HAZOP是有效的医疗安全管理培训方法。要解决的一个问题是每次会议花费太多时间，我们计划开发计算机软件来帮助讨论。

Although a number of incident reports are collected in a hospital to improve patient safety management, it is difficult to eliminate all medical errors. An educational approach is essential to promote a strong consciousness of patient safety especially in a resident.Hazard And Operability Studies (HAZOP) is one of risk analysis methods having developed in a process industry such as chemical plants in 1970's. HAZOP is constituted by three steps, analyzing an operation in a step-wise fashion (called Work Breakdown Structure), discussing error causes and consequences, and mapping them onto a risk matrix. A main character of HAZOP differed from FMEA (Failure Mode and Effect Analysis) is that a discussion is proceeded in accordance with guide words, which enables to cover all the possibilities.To develop HAZOP as a new educational approach of medical safety management, we had a lot of group works with residents, orthopedic doctors, nurses, and co-medical staffs in a trial basis. The themes for residents were tracheal intubation, epidural tubing, and central venous catheterization ; the themes for medical doctors endoscopic lumbar disc surgery and total hip replacement ; the themes for co-medical staffs accidental fall of in-patients and management of prescriptions.Most of participants evaluated HAZOP as an effective training method for medical safety management. An issue to be solved was taking too much time for a session, and we plan to develop computer software to help discussion.