医疗失效模式与效应分析在预防住院精神病患者跌倒中的应用

Application of healthcare failure mode and effect analysis on the prevention of falls in hospitalized patients with mental disorders

目的：应用医疗失效模式与效应分析（ HFMEA）预防住院精神病患者跌倒事件的发生，提高护理质量，保障患者安全。方法根据HFMEA方法，成立防跌倒小组；绘制防跌倒流程图，进行失效模式与潜在风险原因分析，计算事先风险指数（ RPN）；找出关键失效模式及相关原因，制订改进方案并落实。结果本院实施HFMEA后，5项关键模式的RPN值明显低于实施前（ P〈0.05）；住院患者的跌倒率由实施前的0.64％下降到0.28％。结论运用HFMEA管理方法对跌倒发生的潜在失效模式进行根本原因分析及流程改进，可降低跌倒发生率，提高护理质量。

Objective To reduce the incidence of psychotic inpatients fall events , improve the quality of care and ensure patient safety using healthcare failure modes and effects analysis （HFMEA）.Methods According to HFMEA method, we set up anti-fall group, drew anti-fall flow chart, performed causes analysis of failure mode and potential risks, calculated risk priority number （RPN）, identified critical failure modes and related causes, developed improvement programs and implemented.Results After the implementation of the HFMEA, RPN value of five key patterns were significantly lower than before （ P〈0. 05）. 0. 64% fall rate before the implementation in hospitalized patients decreased to 0. 28%. Conclusions It can reduce the incidence of falls and improve the quality of nursing care using the HFMEA management to perform root cause analysis and process improvement of potential failure modes of falls.