医疗失效模式与效应分析在压疮高危病人风险管理中的应用研究

Application study on health care failure mode and effect analysis in risk administration of high-risk pressure ulcer patients

[目的]运用医疗失效模式与效应分析(HFMEA)对压疮高危病人进行风险评估及质控流程再造,改善压疮高危病人风险管理。[方法]以2009年—2011年住院病人为对照组,实施常规压疮高危因素评估质控流程;2012年—2014年住院病人为观察组,实施基于HFMEA管理模式的压疮高危因素评估质控再造流程;比较两组住院病人的压疮高危备案率、压疮发生率及观察组实施后事先风险指数(RPN)改善情况。[结果]观察组较对照组压疮高危病人备案率上升、压疮发生率下降(P<0.01),观察组实施HFMEA管理模式后RPN值下降(P<0.01)。[结论]将HFMEA应用于压疮高危病人管理,可准确把握防范压疮的重点管理环节,防患于未然,有效降低压疮高危病人的压疮发生率。

Objective： Applying healthcare failure mode and effect analysis （HFMEA） to transform the quality control process of pressure ulcer risk factors assessment, so as to improve the risk management. Methods：The patients in hospital from 2009 to 2011 were taken as the control group which implemented the conventional quality control process of pressure ulcer risk factors assessment, while the patients from 2012 to 2014 were taken as experimental group which implemented the new quality control process of HFMEA. The situation of two groups patients with pressure ulcers record rate, the incidence and risk index（RPN） were compared between both groups. Results：The pressure ulcers record rate and incidence of two groups had shown significantly different（P〈0.01）. The RPN of experimental group reduced after implementing HFMEA management mode（P〈0. 01）. Conclusion：Applying the HFMEA management mode for the high - risk pressure ulcer patients can accurately key prevent pressure ulcers management link of and precautions, effectively reduce the incidence of pressure ul- cers in patients at high risk of pressure ulcers.