护理学报 ›› 2023, Vol. 30 ›› Issue (11): 36-40.doi: 10.16460/j.issn1008-9969.2023.11.036
医疗失效模式与效应分析在规范护理工作流程中的应用进展
李娜1,2, 熊晓云1, 郑青玉1, 涂萍1, 黎丽兰1
- 1.南昌大学第二附属医院,江西 南昌 330000;
2.南昌大学医学院 护理学院,江西 南昌 330000
摘要： 目的 综述医疗失效模式与效应分析在规范护理工作流程的应用进展,为其在其他护理领域的应用提供参考。方法 检索国内外相关文献,从发展背景、实施步骤及其在规范化护理工作流程中的应用现状进行总结归纳和分析。结果 医疗失效模式与效应分析有利于护理工作流程的规范化构建,但在应用时会面临研究小组组建不规范、风险优先值评分主观化等问题。结论 以医疗失效模式与效应分析为理论框架构建的规范化护理工作流程,是一种可降低风险因素发生,保障患者安全的有效方法。未来应加强对其深入研究,制定精简、规范的研究步骤,开展多学科、多理论的联合应用,以加速推动其在复杂临床环境中构建规范化护理流程的应用进展。
中图分类号:
- R47
| [1] Mora A, Ayala L, Bielza R, et al.Improving safety in blood transfusion using Failure Mode and Effects Analys[J].Transfusion,2019,59(2):516-523 DOI:10.1111/trf.15137. [2] World Health Organization. Patient safety [EB/OL]. (2018-09-01).http://www.who.int/news-room/facts-in-pictures/detail/patient-safety. [3] Liu HC, Zhang LJ, Ping YJ,et al.Failure Mode and Effects Analys for proactive healthcare risk evaluation: a systematic literature review[J]. J Eval Clin Pract,2020,26(4):1320-1337. DOI:10.1111/jep.13317 [4] DeRosier J, Stalhandske E, Bagian JP, et al. Using Healthcare Failure Mode and Effect Analysis: the VA National Center for Patient Safety's prospective risk analysis system[J]. Jt Comm J Qual Improv,2002,28(5):248-267. DOI:10.1016/s1070-3241(02)28025-6. [5] Alamry A, Al Owais SM, Marini AM, et al.Application of Failure Mode Effect Analysis to improve the care of septic patients admitted through the emergency department[J]. J Patient Saf,2017,13(2):76-81. DOI:10.1097/PTS.0000000000000118. [6] World Health Organization.Medication without harm - global patient safety challenge on medication safety[EB/OL].(2017-06-01). https://www.who.int/publications/i/ item/WHO-HIS-SDS-2017.6. [7] Elliott RA,Camacho E,Jankovic D,et al.Economic analysisi of the prevalence and clinical and economic burden of medication error in England[J].Br Med J Qual Saf,2021,30(2):96-105. DOI: 10.1136/bmjqs-2019-010206. [8] Aldhwaihi K, Schifano F, Pezzolesi C, et al.A systematic review of the nature of dispensing errors in hospital pharmacies[J]. Integrated Pharmacy Research Practice, 2016, 5: 1-10. DOI: 10.2147/IPRP.S95733. [9] 李红云,汪惠,边书芹等.医疗失效模式与效应分析在儿科静脉用药调配中的应用[J].护理学报,2020,27(20):12-16.DOI:10.16460/j.issn1008-9969.2020.20.012. [10] Abbassi A, Ben Cheikh Brahim A,Ouahchi Z. Failure Mode and Effect Analysis applied to improve the medication management process in a pharmacy of a teaching hospital and a proposal for a simplified rating system[J].Eur J Hosp Pharm,2023,30(e1):e55-e60.DOI:10.1136/ejhpharm-2021-003013. [11] Anjalee L, Rutter V,Samaranayake R.Application of Failure Mode and Effects Analys (FMEA) to improve medication safety in the dispensing process - a study at a teaching hospital, Sri Lanka[J]. BMC Public Health, 2021,21:1. DOI: 10.1186/s12889-021-11369-5. [12] Pearse RM, Beattie S, Clavien PA, et al.Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle-and high-income countries[J]. Br J Anaesth,2016,117(5):601-609. DOI:10.1093/bja/aew316. [13] Pirouzi M, Gorji H, Ravaghi H, et al.Health Care Failure Mode and Effect Analysis in the operating room setting[J]. Quality Management in Health Care, 2020, 29(4): 234-41. DOI: 10.1097/QMH.0000000000000248. [14] 陈红,张春瑾,吴波,等. 医疗失效模式与效应分析在术中获得性压力性损伤风险管理中的应用[J].中国护理管理,2022,22(5):713-717. DOI:10.3969/j.issn.1672-1756.2022.05.015. [15] Heideveld-Chevalking AJ, Calsbeek H, Hofland J, et al.Prospective methods for identifying perioperative risk-assessment methods for patient safety over 20 years: a systematic review[J]. BJS Open,2020,4(2):197-205. DOI: 10.1002/bjs5.50246. [16] Frietsch T, Thomas D, Schöler M, et al.Administration safety of blood products - lessons learned from a national registry for transfusion and hemotherapy practice[J]. Transfus Med Hemother, 2017,44(4):240-254. DOI:10.1159/000453320. [17] Haroun A, Al-Ruzzieh MA, Hussien N,et al.Using Failure Mode and Effects Analys in improving nursing blood sampling at an International Specialized Cancer Center[J]. Asian Pac J Cancer Prev,2021,22(4):1247-1254. DOI: 10.31557/APJCP.2021.22.4.1247. [18] Kaufman RM, Dinh A, Cohn CS, et al.Electronic patient identification for sample labeling reduces wrong blood in tube errors[J]. Transfusion,2018, 59(3):972-980. DOI: 10.1111/trf.15102. [19] Smith FC, Donaldson J, Pirie L.Pre-registration adult nurses' knowledge of safe transfusion practice: results of a 12-month follow-up study[J]. Nurse Educ Prac,2010,10(2):101-107. DOI:10.1016/j.nepr.2009.04.003. [20] Dehnavieh R, Ebrahimipour H, Molavi-Taleghani Y, et al.Proactive risk assessment of blood transfusion process, in pediatric emergency, using the Health Care Failure Mode and Effects Analys (HFMEA)[J]. Glob J Health Sci,2014,7(1):322-331. DOI: 10.5539/gjhs.v7n1p322. [21] Aly N, El-Shanawany S, Maher Ghoneim T.Using Failure Mode and Effects Analys in blood administration process in surgical care units:new categories of errors[J].Quality Management in Health Care, 2020, 29(4):242-252. DOI:10.1097/QMH.0000000000000273. [22] 陈岚,熊永芬,王顺.医疗失效模式与效应分析对术中输血安全性的影响研究[J].中国输血杂志,2020, 33(5):532-534.DOI:10.13303/j.cjbt.issn.1004-549x.2020.05.033. [23] Barnett R.Acute myocardial infarction[J].Lancet,2019,393(10191):2580-2584.DOI:10.1016/S0140-6736(19)31419-9. [24] Samim SA, Singh A, Ravi P.Modified early warning system: quality improvement with the help of Healthcare Failure Modes and Effect Analysis[J]. Hosp Top,2020,98(3):108-117. DOI: 10.1080/00185868.2020.1788476. [25] 马琴. HFMEA在ST段抬高型心肌梗死患者急诊诊疗流程中的应用[D].广州:南方医科大学,2021.DOI:10.27003/d.cnki.gojyu.2021.000294. [26] Prekker ME, Delgado F, Shin J, et al.Pediatric intubation by paramedics in a large emergency medical services system: process, challenges, and outcomes[J]. Ann Emerg Med, 2016,67:20-29. DOI: 10.1016/j.annemergmed. [27] Zhang W, Lv J, Zhao J, et al.Proactive risk assessment of intrahospital transport of critically ill patients from emergency department to intensive care unit in a teaching hospital and its implications[J]. J Clin Nurs,2022,31(17/18):2539-2552. DOI: 10.1111/jocn.16072. [28] Chilakamarri P, Finn EB, Sather J, et al.Failure Mode and Effect Analysis: engineering safer neurocritical care transitions[J]. Neurocrit Care,2021,35(1):232-240. DOI:10.1007/s12028-020-01160-6. [29] 张燕,杨芸,徐芳芳.失效模式与效应分析在急诊急危重症患者院内转运中的应用[J].中国医药导报, 2022,19(31):186-189.DOI:10.20047/j.issn1673-7210.2022.31.44. [30] 赵艳莉,胡慧,生辉.供应室骨科外来器械管理应用失效模式与效应分析效果观察[J].齐鲁护理杂志, 2020,26(10):101-103. [31] Yi L, Chen Y, Hu R, et al.Application of Healthcare Failure Mode and Effects Analys in controlling surgical instrument packaging defects[J]. Sci Rep,2022,12(1):19708.DOI: 10.1038/s41598-022-24282-7. [32] Linkin DR, Sausman C, Santos L, et al.Applicability of Healthcare Failure Mode and Effects Analys to healthcare epidemiology: evaluation of the sterilization and use of surgical instruments[J]. Clin Infect Dis,2005, 41(7):1014-1019. DOI: 10.1086/433190. |
| [1] | 张海波, 黄润, 吴芳. 基于医疗失效模式与效应分析优化体外循环术后患者应激性高血糖管理流程的效果评价[J]. 护理学报, 2023, 30(5): 28-32. |
| [2] | 朱红, 刘争, 王垭, 张蒙, 宋锦平. 基于三维质量评价模式构建住院患者非计划拔管风险管理质量评价体系[J]. 护理学报, 2022, 29(1): 7-12. |
| [3] | 管艳, 卢山, 叶家欣, 王哲芸. 心脏术后压力性损伤规范化实践方案的构建与应用[J]. 护理学报, 2021, 28(7): 15-20. |
| [4] | 戴利, 王民心, 叶艳兰, 罗静珍, 杨云智. 新型冠状病毒肺炎疫情期间社区居家护理感染防控应用失效模式效应分析的效果观察[J]. 护理学报, 2020, 27(9): 59-63. |
| [5] | 蔡忠香, 方婷, 范婧慧, 杨欣, 王雪芬, 鲜于云艳, 刘春英, 张美芳. 新型冠状病毒肺炎疫情期间护理管理应急问题及对策[J]. 护理学报, 2020, 27(5): 76-78. |
| [6] | 张娟, 黄蓓蓓, 余天浩, 刘夕珍, 顾静. 基于医疗失效模式与效应分析模型的急性缺血性脑卒中患者院内急救流程优化[J]. 护理学报, 2020, 27(4): 16-20. |
| [7] | 陈梦云, 谢漫, 杨素敏, 李玲. SBAR模式在护理优良事件分享学习管理中的应用[J]. 护理学报, 2020, 27(3): 18-21. |
| [8] | 李红云, 汪惠, 边书芹, 芦霜, 张继芝. 医疗失效模式与效应分析在儿科静脉用药调配中的应用[J]. 护理学报, 2020, 27(20): 12-16. |
| [9] | 郭思明, 杨鑫, 王敏, 赵连童. 35例无痛消化内镜手术患者术中穿孔镜下闭合的护理[J]. 护理学报, 2019, 26(8): 61-64. |
| [10] | 卞伶玲, 杨金娜, 赵益, 杨雨佳. 双腔Power PICC置管部位医用粘胶剂相关性皮肤损伤的风险预防管理[J]. 护理学报, 2019, 26(6): 64-66. |
| [11] | 金环, 喻姣花, 李鑫, 王玉梅, 李瑶. 护理不良事件人因可靠性数据库的设计与应用[J]. 护理学报, 2019, 26(3): 8-11. |
| [12] | 钟笑媚, 徐素婷, 徐信兰, 林艳. 输液外渗不良事件上报系统的设计与应用[J]. 护理学报, 2019, 26(23): 33-35. |
| [13] | 于丰, 胡德英, 孙丽, 代艺, 刘敏, 张佳. 小组式护理论坛在肿瘤科患者自杀防治培训中的应用与启示[J]. 护理学报, 2019, 26(17): 14-17. |
| [14] | 周淑芬,刘翠青,谢翠媚,李延飞,卢溢樟. 护理不良事件与安全隐患上报双轨化管理的实施效果[J]. 护理学报, 2018, 25(5): 24-26. |
| [15] | 宋杰,章洁,高远,皮红英. 护理不良事件非结构上报内容的自然语言处理及效果比较[J]. 护理学报, 2018, 25(3): 1-4. |
|