医疗失效模式与效应分析对术中输血安全性的影响研究

Healthcare failure mode and effect analysis:an application in improving the safety in intraoperative blood transfusion

目的探讨医疗失效模式与效应分析(HFMEA)在术中输血安全管理中的应用效果。方法运用HFMEA分析并列出静脉输血流程中的潜在失效模式,计算每个失效模式的危机值(RPN),筛查出RPN>125分的失效模式,对其风险因素进行分析,然后制定出针对性的改进措施。对2017年6月—2018年6月实施HFMEA后的临床输血护理质量检查结果进行统计并作为观察组,将2016年4月—2017年4月实施HFMEA前的临床输血护理质量检查作为对照组。比较实施HFMEA前后高危失效模式的RPN值,以及2组护理差错及输血不良反应发生率。结果实施HFMEA后高危失效模式的RPN值均较实施前低(RPN因人为因素数值不同);观察组护理差错及输血不良反应发生率(对照组1.36%,观察组0.42%)均较对照组低(P<0.05)。结论运用HFMEA进行手术室输血安全管理,可减少护理差错,降低输血不良反应的发生风险。

Objective To explore the application effect of Healthcare Failure Mode and Effect Analysis(HFMEA) in reducing risks of problems inherent in the procedure of intraoperative blood transfusion. Methods The major steps of HFMEA were to outline the potential failure modes in the procedure of venous transfusion, and then calculate the likelihood of failure occurrence which were multiplied and reported as a risk priority number(RPN) for each failure mode. Solutions(process redesign actions) were developed to address the failure modes with RPNs>125 scores.The results of nursing quality examination of clinical blood transfusion in the 12 months(June 2017 to June 2018) following the implementation of HFMEA were statistically analyzed and served as the observation group, and the results in the same period(April 2016 to April 2017) prior to the implementation of HFMEA was used as the control group. The high RPNs suggesting high risk failure modes, nursing errors and incidence of adverse reactions were compared between the two groups. Results The RPNs of high risk failure modes after the implementation of HFMEA were lower than those prior to the implementation. The incidence of nursing errors and adverse reactions to blood transfusion in the observation group(0.42%) were lower than those in the control group(1.36%). Conclusion HFMEA is a valuable tool in improving the blood transfusion process during surgery, which contributes to prevent serious, avoidable errors and decrease the incidence of adverse reactions to transfusion.