第六章 結論與建議
第二節 建議
一、 對衛生主管建議
1. 跟隨國際趨勢，升級本國 RCA 調查工具為 2.0 版，推廣應用 HFACS 標準化工 具於醫院醫療不良事件根因調查。
2. 輔導醫院內部培訓跨專業領域之根本原因分析調查員。
3. 鼓勵醫療機構以正向學習的文化，持續進行通報以及根因調查。
4. 培育台灣 HFACS 專家，由外部的第三方(Outsider)，組成根本原因分析小組進 行醫院重大不良事件調查，更客觀中立。
5. 積極投注更多研究於此領域，建立長期國家級異常事件根本原因分析調查資料 庫，與世界接軌。
6. 建議積極投注資源發展全套中文化 HFACS 醫療版教材，包含 HFACS 快速參考 指引、訪談指引、微分類碼、HFIX(Human Factor Intervention matriX)等，更臻 完善。
二、 對醫療機構管理者與病安實務工作者建議
1. 持續營造機構內部的正向病安文化，建立暢通、公開透明的管道，由異常事件 調查分析結果中正向學習，避免再發生。
2. 監督與組織層級的支持，養成全體員工對異常事件根因調查正向的觀念與認知。
3. 積極投注資源，培育各職類根本原因分析調查員群，提供足夠的教育訓練，長 期累積經驗，應用 HFACS 於根本原因分析調查，以更完整全面掌握人為因素。
4. 效仿航空界經驗，邀請心理學專家加入 RCA 調查小組，更深入剖析人類思維與 行為。
5. 積極了解並排除影響根因調查時的障礙與困難，營造一個安全安心的調查環 境，減少事件相關人員排斥與抗拒，善用 HFACS 訪談指引，加強調查員之訪談 技巧訓練，建立員工事故關懷機制以及事發對象的身心輔導。
6. 在案件回饋與追蹤方面，建議應更落實執行，成為常態。
7. 隨著科技日新月異，錯誤的型態轉型，呼籲醫療機構即將面臨資訊科技帶來病 安風險的挑戰，醫院應積極培養人員對人為因素的認識以及導入人因工程以發 展有效之對策，以維護病人安全。
三、 對個案醫院之建議
1. 升級 RCA 調查工具為 2.0 版，前瞻應用 HFACS 工具於醫療不良事件根因調查。
2. 積極培訓跨專業領域之根本原因分析調查員。
3. 效仿航空界經驗，邀請心理學專家加入 RCA 調查小組，更深入剖析人類思維與 行為。
7. 積極投注更多研究於此領域。
四、 對未來研究者建議
1. 採前瞻性調查法，應用此工具輔助進行根本原因分析調查，系統邏輯性的全面 性評估人為因素在不良事件中的可能影響。
2. 醫療為複雜的系統，不良事件人為因素各層次間具有因果關係，貢獻因子間相 互影響，常常是多職類人員、多步驟動作，要釐清其因果關係，相較其他高風 險行業不易。有待未來更多的研究深入探討各層級間、不同類型案件之因果路 徑關係。
3. 在醫療領域，病人及照顧者(含家屬、照顧服務員、外籍照護者等)是造成不良事 件的重要因素，建議對此部分未來可加以深入研究。
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