医疗失效模式与效应分析预防脊柱手术压疮风险的应用研究

Application of health failure mode and effect analysis in the prevention of pressure sore in spine surgery patient

目的:探讨医疗失效模式与效应分析(HFMEA)在预防脊柱手术患者压疮发生中的应用效果。方法:组建脊柱手术俯卧位患者压疮HFMEA小组,对2014年10月至2015年3月脊柱后路手术患者可能发生压疮的原因进行分析,找出需要干预的风险因素,计算出风险指数(RPN),绘制并改进压疮风险预防流程图,从而最终确定失效模式分析并确认根本原因,列出需要改善的失效模式,拟定行动计划并组织实施,并与实施HFMEA前(2014年5月至2014年9月)RPN值进行比较。结果:实施HFMEA流程改进后,失效模式的RPN评分均较改进前明显下降(P<0.01)。压疮预防效果评估与流程改进前,发生压疮6例,改进后,无压疮发生,差异有统计学意义(P<0.05)。结论:应用HFMEA对脊柱手术俯卧位患者进行原因分析及针对性地流程改进,可以有效地预防患者压疮风险的发生,提高手术室护理质量。

Objective：To explore the effects of health failure mode and effect analysis（ HFMEA） on the prevention of pressure sore in spine surgery patients. Methods：The formation of HFMEA group of pressure sore in patients with spinal surgery in prone position was established,the reason of sore in the patients treated with spine surgery in prone position were analyzed between October 2014 and March 2015. The basic reasons of sore were identified by finding out the risk factors of need intervention,calculating the RPN and drawing the flow diagram of risk prevention of pressure sores,which was used to list the improvement failure mode,formulate,organize and implement the action plan. The RPN was compared before and after implementing HFMEA. Results：The RPN of failure mode significantly decreased after improving the flow diagram（P〈0. 01）. Six cases with pressure sores before improvement and no case with pressure sore after improvement were found,the difference of which was statistically significant（P 〈 0. 05）. Conclusions：The application of HFMEA in cause analysis and process improvement in prone position patient with spine surgery can effectively prevent pressure sore,and improve the nursing quality in operation.