医疗失效模式与效应分析在新生儿中心静脉导管相关性血流感染中的应用  

Health care failure mode and effect analysis of reducing NICU line-associated bloodstream infections

作　　者：刘海霞[1] 蔡洁贞[1] 陈瑞玲[1] 胡蓉[1] 梁丹清[1] 王瑞华[1] 曹巧玲[1] 

机构地区：[1]深圳市龙岗区人民医院儿科,广东深圳518172

出　　处：《泰山医学院学报》2014年第9期904-906,共3页Journal of Taishan Medical College

摘　　要：目的探讨降低重症监护室新生儿中心静脉感染发病率的措施。方法运用医疗失效模式与效应分析中心静脉插管、维护及移除等关键环节,实施包括再教育、实践改善、审核和结果评估的干预方案。结果运用医疗失效模式与效应分析鉴别出五个有助于中心静脉感染的常见失效模式,包括污染物、次优的医疗环境、文件的失误、敷料完整性的评估、设备问题、理论知识的缺乏。在实施了适当的干预方案后,新生儿重症监护室内每1000人/天中心静脉感染发生率由2.6降低至0.8。结论医疗失效模式与效应分析有助于减少新生儿中心静脉感染的发生;有助于新生儿重症监护室的质量改进和完善。ObJective：To explore measures of reducing the incidence of central line-associated bloodstream infections （CLABSIs）. Methods：The concept of“health care failure mode and effect analysis”（HFMEA）was used to analyze cen-tral line insertion,maintenance,and removal practices. We completed the HFMEA process and implemented intervention plan that included reeducation,practice changes,auditing and outcome measures. Results：The HFMEA identified 5 com-mon failure modes that contributed to the development of CLABSIs,including contamination,suboptimal environment of care,improper documentation and evaluation of central venous catheter dressing integrity,issues with equipment and lack of knowledge. After implementing the appropriate actions,CLABSIs in the NICU markedly decreased. Conclusion：The process of HFMEA helps reduce the CLABSI rate and continuous quality improvement and safety in the NICU.

关 键 词：医疗失效模式与效应分析 中心静脉血液感染 新生儿重症监护 

分 类 号：R473.72[医药卫生—护理学]