失效模式与效应分析在重症监护室高危药品安全管理中的应用

Utility of Failure Mode and Effect Analysis to Improve the Safety of High-Risk Drug Management in Intensive Care Unit

目的 识别重症监护室(intensive care unit,ICU)高危药品管理过程中潜在的风险,为科学有效提高病区高危药品管理质量提供依据.方法 运用失效模式与效应分析(failure mode and effect analysis,FMEA)工具,对病区高危药品管理流程进行分析,通过计算风险优先指数(risk priority numbers,RPN)值查找每个流程中潜在的高危因素,并对RPN>125的关键环节制定并实施改进方案.结果 使用FMEA后,7个RPN>125的高危环节通过制定并实施改进防范措施,RPN值均降至125以下.高危药品管理缺陷发生率由8.974%降至4.225%,与实施前比较,差异有统计学意义(P=0.037).结论 将FMEA运用于ICU高危药品的管理中,可有效提高病区高危药品管理质量,保障患者用药安全.

Objective To identify the potential risks in the process of high-risk drug management in intensive care unit(ICU),so as to provide a basis for the scientific and effective improvement of high-risk drug management quality in the ward.Methods The concept of failure mode and effect analysis(FMEA) was used to analyze the management of high-risk drug in ICU,and to find out the potential high-risk factors in each process by calculating the risk priority numbers(RPN),and to develop and implement the improvement scheme for the key links of RPN>125.Results After the implementation of FMEA,seven high-risk links with RPN values greater than 125 were all reduced to below 125 by the development and implementation of preventive measures.The incidence of high-risk drug management defects decreased from 8.974% to 4.225%,the difference was statistically significant(P=0.037).Conclusions The application of FMEA in the management of high-risk drugs in ICU can effectively improve the quality of high-risk drugs management in the ward and ensure the safety of patients’ medication.