运用失效模式及效应分析改善临床给药流程的探讨

Using failure mode and effect analysis to improve clinical dosing process

目的对临床给药流程进行改造，以减少用药流程的风险。方法运用失效模式及效应分析的基本步骤，成立流程改进工作小组，列出临床给药的流程，指出子流程下可能导致差错的环节及原因。提出优先解决的问题及流程整改方案，设计新型的临床给药流程。结果新旧给药流程优先风险数值比较差异有显著性（P〈0．01）；改造后用药相关缺陷从4例下降至2例。结论将失效模式及效应分析对临床护理给药流程进行分析，能前瞻性地发现工作流程中潜在的缺陷，使管理者发现流程中应该优先解决的问题，为护理工作流程改造提供科学的方法，确保病人用药安全。

Objective To improve clinical dosing process and reduce the risk of clinical dosing. Methods We used the basic step of Failure Mode and Effect Analysis and establish process improvement working group. Then list out clinical dosing process, point out parts and reasons, which probably lead to errors in branch proess. Discuss and study the priority problem and draw out improvement scheme. Design new clinical dosing process, Results The result showed signifieant differences between two processes in risk value（ P〈0.01 ）. Clinical dosing error descended from 4 cases to 2 cases. Conclusion Clinical dosing process with failure mode and effect analysis can find out potential errors ,predictability and priority problem solution, providing clinical working process with scientific methods and keeping safety in dosing.