应用失效模式与效应分析预防和减少住院患者跌倒意外

Failure mode and effect analysis in prevention and reduction of falls in hospitalized patients

目的运用失效模式与效应分析（FMEA）改进住院患者防跌倒流程及措施，降低跌倒的发生率。方法对2011年1月至12月住院的32775例试验组患者运用FMEA方法分析失效模式与潜在原因，计算优先风险指数（RPN）值，改进需优先解决问题的相关措施，随访整改成效，并与2010年1月至12月住院的29500例仅接受医院常规跌倒管理的患者比较跌倒发生率。结果实施FMEA管理模式后2011年较2010年跌倒失效模式RPN值下降81．78％，跌倒发生率由0．44％0下降至0．12％。结论应用失效模式与效应分析法有助于预防和减少跌倒发生，有力地保障患者安全。

Objective To improve fall prevention process and measures by using failure mode and effect analysis （FMEA）, in order to reduce the incidence of falls in hospitalized patients. Methods 29,500 patients in our hospital from January to December 2010 were enrolled as a control group, and 32,775 patients hospitalized from January to December 2011 were recruited as a study group. The control group only received regular management system Io prevent falls. A fall prevention group was established in the study group to analyze the causes of falls using the FMEA method. The preferred risk index （RPN） was calculated, the measures were made to solve the relevant problems, and the improved effect was tracked. Restdts The number of RPN was declined by 81.78% in 2011 after implementation of FMEA, as compared with the number in 2010. And the incidence of falls declined from 0.44%0 to 0.12 %. Conclusions Application of failure mode and effect analysis is helpful in the prevention and reduction of falls and effectively guarantee patient safety.