医疗失效模式与效应分析在新生儿卡介苗接种流程中的应用

目的运用医疗失效模式与效应分析(health care failure mode and effect analysis,HFMEA)规范新生儿卡介苗(bacille calmette-Guerin vaccine,BCG)接种流程,并评估应用效果。方法组建HFMEA项目团队,根据HFMEA模式规范新生儿BCG接种流程。便利抽样法选取国际和平妇幼保健院2015年出生的新生儿为观察组,2010-2014年出生的新生儿为对照组,比较规范接种前后两组新生儿在BCG使用情况及BCG疑似预防接种异常反应(adverse events following immunization,AEFI)报告发生率之间的差异。结果应用HFMEA模式规范BCG接种流程后,新生儿BCG及时接种率由96.16%升至97.36%(P0.01),BCG的AEFI报告发生率由493.32/100万剂次降至68.78/100万剂次(P0.05)。结论应用HFMEA模式规范BCG接种流程,可提升BCG及时接种率及疫苗接种工作的安全性。

Application of Health Care Failure Mode and Effect Analysis in BCG Inoculation Process of the Newborn

Objective To use health care failure mode and effect analysis (HFMEA) to regulate bacillus calmette Guerin vaccine (BCG) inoculation process in our hospital and evaluate effect of application.Methods Setted up HFMEA project team and accorded to HFMEA mode to regulate BCG inoculation process of the newborn.Selected the newborn who born in 2015 as observation group,the newborn who born in 2010 to 2014 as control group,compared difference of vaccine using status and BCG adverse event following immunization (AEFI) before and after standard inoculation of the newborn.Result After applying HFMEA mode and regulate BCG inoculation process,BCG timely inoculation rate of the newborn increased from 96.16％ to 97.36％(P＜0.01),the AEFI report occurrence rate of BCG reduced from 49.3 thousand per agent to 6.9 thousand per agent(P＜0.05).Conclusions Applying HFMEA model to regulate BCG inoculation process will improve BCG timely inoculation rate and safety of vaccine inoculation work.