FMEA结合RCA预防非计划性拔管的效果分析  

Prevention of unplanned extubation through failure mode and effects analysis and root-cause analysis

作　　者：薛美琴[1] 张玲娟[1] 钱火红[1] 胡敏[1] 

机构地区：[1]第二军医大学附属长海医院护理部,上海200433

出　　处：《护理学杂志》2013年第19期54-56,共3页

摘　　要：目的减少非计划性拔管的发生,提高护理质量,确保患者安全。方法结合失效模式与效应分析(FMEA)和根本原因分析(RCA)两种质量改进方法,成立分析团队,绘制流程图,列出潜在失效模式,对4个病区展开管道护理防范措施落实情况调查,找出根本原因,提出改善措施并落实。结果干预后管道护理防范措施中5项高风险失效模式的RPN值低于实施前;干预后6个月内的非计划性拔管率低于干预前6个月。结论FEMA与RCA相结合的方法,可有效降低非计划性拔管的发生,但其结合方法仍待进一步完善,也仍需要大样本临床研究提供偱证依据。Objective To reduce the incidence rate of unplanned extubation, enhance the quality of nursing care, and to ensure patient safety. Methods We combined the methods of failure mode and effects analysis（FMEA） and root-cause analysis （RCA）, established an analysis team, drew up a flow chart, listed out potential failure modes, conducted a field survey on unplanned extubation in 4 units, tracked down the root causes, put forward improvement skemes and implemented them. Results After implementing the mea sures, the risk priority number （RPN） values of top 5 failure modes decreased; and the incidence rate of unplanned extubation with in 6 months after implementing the measures, was lower than that over a 6-month period before the measures. Conclusion The com- bination of FEMA and RCA can effectively prevent unplanned exbubation, but the bonding of the two methods needs further im provement, and the effectiveness requires more large sample clinical studies to prove.

关 键 词：非计划性拔管 失效模式与效应分析 根本原因分析 

分 类 号：R47[医药卫生—护理学] C931.2[医药卫生—临床医学]