运用失效模式及效应分析对住院病人口服给药流程改造的效果分析

目的对住院病人用药流程进行改造，以减少口服用药流程的风险。方法运用失效模式及效应分析的基本步骤，成立流程改进工作小组，列出口服用药的流程，指出子流程下可能导致差错的环节及原因，提出优先解决的问题及流程整改方案，设计新型的口服药袋并改由药师查对药品的一系列方法。结果新旧口服用药流程优先风险数值比较差异有统计学意义（P〈0．01）；改造后用药相关缺陷率从1．79％下降至0．39％，差异有统计学意义（P〈0．05）。结论将失效模式及效应分析对护理工作流程进行分析，能前瞻性地发现工作流程中潜在的缺陷，使管理者发现流程中应该优先解决的问题，为护理工作流程改造提供科学的方法，提高护理工作的安全性。

Effect analysis of transformation of oral medication flow for inpatient using Failure Mode and Effect Analysis

Objective To transform the oral medication flow for inpatient in the purpose of reducing deftciency in oral medication.Methods Using the fundamental steps of Failure Mode and Effect Analysis (FMEA).a flow transformation team were formed,the oral medication flow was list and each failure mode,reasons were poinmd out,the prefered problems to solved and the transformation mode were suggested.Then,the team gave transformation measures as follows:developing new medication bags and checking the oral medicine by apothecary.Results The sores of prefered risk radio decreased(P<0.01).The incidence of oral medication deficiency decreased significantly(1.79%VSO.39%),the differences were significant(P<0.05).Conciusions As a flow management tool.FMEA can discover potential deficiency in advance and the prefered problems solved by nursing administrators,provide the scientic method for nursing transformation and improve the safty for nursing.