运用失效模式及效应分析对住院病人口服给药流程的改造

目的运用失效模式及效应分析(failuremode and effects analysis,FMEA)对住院病人用药流程进行改造,以减少口服用药缺陷的发生。方法根据FMEA方法,成立流程改进工作小组;列出口服用药的流程;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;跟踪整改的成效。结果流程改进后失效模式的优先风险数值及口服用药缺陷发生率显著下降,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,能前瞻性发现流程中潜在的漏洞,使护理管理者能"因病施治",充分发挥系统防御对缺陷的屏蔽功能。

Objective To reform the medication flow-sheet by using failure mode and effects analysis （FMEA） to reduce the occurrence of oral medication defect. Methods According to FMEA, the reformed flow were as following： a flow-sheet reforming panel was set up; oral medication flow-sheet was formulated; possible mistakes 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; the reforming effectiveness was followed up. Results The RPN value of FMEA decreased dramatically. The difference was significant （P 〈 0.05）. Conclusions FMEA, as a risk management tool, can discover potential loopholes in the flow-sheet prospectively. Thereafter, nursing managers can adopt corresponding measures and make full use of systematic defense for shielding defects.