失效模式与效应分析预防住院患者跌倒的实践与探讨

Practice and Discussion of Applying Failure Mode and Effect Analysis in Preventing Inpatients from Falls

目的探讨运用失效模式与效应分析有效预防住院患者跌倒的方法。方法成立失效模式与效应分析跌倒小组,组织有关人员进行调查,进行失效模式与潜在风险原因分析,计算优先风险指数。结果跌倒失效模式与潜在风险原因的前3位分别为地面湿拖后地滑、感知障碍导致评估不足、医护人员防止跌倒经验不足。实施前和实施后比较住院患者优先风险指数差异有统计学意义(t=4.719,P<0.05)。结论预防住院患者跌倒可采用失效模式与效应分析,有利于降低医疗不良事件的发生。

Objective To explore the effect of applying failure mode and effect analysis in preventing inpatients from falling. Method A failure mode and effect analysis fall prevention team was set up, relevant personnel were organized to investigate and analyze failure mode and potential risks and calculate Risk Priority Number. Result The top 3 causes in failure mode and potential risk analysis were respectively ground landslide after wet mop, insufficient assessment due to perceived barriers, and inadequate prevention experience of medical workers. There was statistically significance between before and after implementation of risk priority number（t= 4.719, P〈0.05）. Conclusion In order to prevent falls, failure mode and effect analysis can be applied to reduce medical adverse events.