从病案编码入手的FMEA分析在降低阴道分娩并发症发生率中的应用

Role of FMEA analysis based on medical record coding in reducing the incidence of vaginal delivery complications

目的 探讨从病案编码入手的失效模式与效应分析管理(failure mode and effect analysis management, FMEA)在降低阴道分娩并发症的应用,为产科医疗质量安全改进提供循证支持。方法 从某院2018—2020年出院病案首页入手,按照国家卫健委监测的阴道分娩并发症疾病编码提取并发症病历。成立FMEA小组全面梳理问题病历,进行多层次、维度剖析阴道分娩并发症潜在影响因素和风险环节,梳理出孕前与孕期、产前、产时、产后4个主流程20个子流程,计算风险指数,并以此将12个极高、高风险点作为改善重点,制定改进措施和政策,对比改进后2021年数据和改进前2020年数据。结果 2021年阴道分娩率较2020年有显著提高(χ2=9.27,P<0.01),阴道分娩会阴切开较2020年显著下降(χ2=96.01,P<0.01),产科裂伤较2020年显著下降(χ2=35.53,P<0.01),产后出血、胎盘胎膜滞留不伴出血对比未见差异有统计学意义(χ2=0.64,χ2=1.91,P>0.05)。故阴道分娩并发症发生率总体降低。结论 从病案编码入手的FMEA分析可助力产科医疗质量安全改进,有效降低阴道分娩风险,后续工作要加强病案编码和首页质控。

Objective To explore the effect of failure mode and effect analysis management model(FMEA) on the complications of vaginal delivery so as to provide evidence-based support for improving the quality and safety of obstetric care.Methods Starting from the first page of the medical records of patients discharged from hospital from 2018 to 2020, the paper extracted the medical records of complications according to the disease codes of vaginal delivery complications monitored by the National Health Commission. A FMEA team was established to comprehensively sort out the problems of medical records and the potential influencing factors and risk links of complications of vaginal delivery were analyzed at multiple levels and dimensions. Four main processes, including pre-pregnancy and pregnancy, prenatal, puerperal and postpartum, together with 20 sub-processes, were sorted out to calculate the risk index, and 12 extremely high and high risk points were taken as the improvement focus, and improvement measures and policies were formulated to compare the data in 2021 after improvement and the data in 2020 before improvement.Results The rate of vaginal delivery in 2021 was significantly higher than that in 2020( χ~2=9.27, P<0.01), vaginal episiotomy was significantly lower than that in 2020( χ~2=96.01, P<0.01), and laceration of soft birth canal was significantly lower than that in 2020( χ~2=35.53,P<0.01). There was no difference in postpartum hemorrhage and placental and fetal membranous retention without bleeding( χ~2=0.64, χ~2=1.91,P>0.05). Therefore, the overall incidence of vaginal delivery complications was reduced.Conclusion The FMEA analysis from the medical record coding can help improve the quality and safety of obstetric medical care and effectively reduce the risk of vaginal delivery. Follow-up work should focus the medical record coding and homepage quality control.