失效模式与效应分析在门诊患者执行输液流程改造中的应用

目的探讨失效模式与效应分析(failure mode and effects analysis,FMEA)在门诊患者执行输液流程改造中的应用效果。方法成立流程改造工作小组;列出门诊患者静脉输液的流程;指出门诊患者"执行输液"子流程中可能导致缺陷发生的环节及原因;提出需要优先解决的问题以及整改措施;追踪整改的效果。结果流程改造后门诊患者"执行输液"流程优先风险指数(risk priority number,RPN)明显降低,改造前后比较,均P<0.05,差异具有统计学意义。结论 FMEA作为一种风险管理工具,能使护理管理者前瞻性地发现门诊患者在执行输液流程中潜在的漏洞与风险,从而降低风险,防范于未然。

Objective To discuss how to apply failure mode and effects analysis （FMEA） to reform the infusion flow -sheet of outpatient.Methods A flow-sheet reforming team was set up;infusion flow-sheet of outpatient was list;possible defects in every step and their causes were pointed out;problems that need to be urgently solved were found out and the flow-sheet was revised;effectiveness of the reforming was followed up.Results The risk priority number（RPN） of the flow-sheet decreased dramatically.The difference was significant（P〈0.05）.Conclusions FMEA,as a risk management tool,can make the nursing managers discover potential loopholes and risks in the infusion flowsheet of outpatient prospectively,adopt pertinent measures,thus reduce risks.