医疗失效模式与效应分析结合根因分析在剖宫产手术部位感染防控中的应用  

Application of healthcare failure mode and effect analysis combined with root cause analysis in the prevention and control of surgical site infections in cesarean section

作　　者：廖丹[1] 韦艳妮 廖桂姨[1] 梁文婷[1] 马张杰[1] 李燕[2] LIAO Dan;WEI Yanni;LIAO Guiyi;LIANG Wenting;MA Zhangjie;LI Yan(Department of Hospital Infection Management,Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region,Nanning,Guangxi 530000,P.R.China;Neonatal Medical Center,Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region,Nanning,Guangxi 530000,P.R.China)

机构地区：[1]广西壮族自治区妇幼保健院医院感染管理科,南宁530000 [2]广西壮族自治区妇幼保健院新生儿医疗中心,南宁530000

出　　处：《华西医学》2025年第3期383-387,共5页West China Medical Journal

摘　　要：目的回顾剖宫产术后感染致子宫切除不良事件,结合风险评估工具制定防控策略,推动围手术期管理标准化,降低孕产妇医疗负担,提升患者满意度。方法以2024年10月—11月某妇产医院产科病房发生的2例因剖宫产术后感染导致子宫切除的事件为研究对象,组建多部门人员的根因分析及风险评估小组,经访谈、观察、查阅资料梳理潜在失效模式与原因,计算风险优先系数(risk priority number,RPN)确定高风险因素,制定并实施改进策略,干预措施实施2个月后,对比干预前后RPN分值及各项措施依从性。结果改进前医疗失效模式风险评估总RPN为367.8分,改进后于2025年1月再次核查,总RPN降至105.7分,未再发生严重不良事件。各项操作依从性和合格率显著提升,孕产妇营养不良干预率从17.5%升至48.6%,术前抗菌药物预防性使用时机合格率从50.5%提升至81.0%,术前使用消毒剂擦洗阴道依从率从15.0%上升至60.0%,术中规范皮肤消毒执行率从66.7%上升至95.2%,术中无菌技术和手卫生操作合格率从75.0%上升至95.2%,感染患者标本送检及时率从29.4%上升到47.6%,差异均有统计学意义(P<0.05)。结论医疗失效模式与效应分析联合根因分析能对围手术期不良事件进行有效改进,优化剖宫产围手术期管理、降低感染风险。Objective To review the adverse event of hysterectomy caused by postoperative infection after cesarean section,formulate prevention and control strategies in combination with risk assessment tools,promote the standardization of perioperative management,reduce the medical burden on pregnant women,and improve patient satisfaction.Methods The two adverse events of hysterectomy caused by postoperative infection after cesarean section that occurred in the obstetrics ward between October and November 2024 were selected as the research objects.A root cause analysis and risk assessment team composed of personnel from multiple departments was established.Through interviews,observations,and data review,the potential failure modes and causes were sorted out.The risk priority number(RPN)was calculated to determine the high-risk factors.Improvement strategies were formulated and implemented.After two-month implementation,the RPN scores and the compliance of various measures before and after the implementation were compared.Results Before the improvement,the total RPN of the healthcare failure mode and effects analysis was 367.8.When rechecked in January 2025,the total RPN after the improvement dropped to 105.7,and no serious adverse events occurred again.The compliance and passing rates of various operations significantly increased:the intervention rate for maternal malnutrition rose from 17.5% to 48.6%,the passing rate of appropriate timing for prophylactic use of antimicrobial agents before surgery increased from 50.5% to 81.0%,the compliance rate of scrubbing the vagina with disinfectant before surgery increased from 15.0% to 60.0%,the implementation rate of standardized skin disinfection during surgery rose from 66.7% to 95.2%,the passing rate of aseptic techniques and hand hygiene operations during surgery increased from 75.0% to 95.2%,and the timely submission rate of specimens from infected patients increased from 29.4% to 47.6%,and all these differences were statistically significant(P<0.05).Conclusion The combination

关 键 词：剖宫产 手术部位感染 医疗失效模式与效应分析 根因分析 围手术期管理 

分 类 号：R47[医药卫生—护理学]