应用失效模式与效应分析预防手术错误

成立手术室失效模式和效应分析（failure mode and effect analysis，FMEA）小组，对2006年所有手术进行手术错误风险评估，通过计算事先风险数，将6个潜在失效原因列为手术错误的高风险因子，分别是接错患者／接手术患者单抄错，接错患者／未与病房护士查对，查对不准确／患者表达能力受限，患者送错手术间／同时接几名患者，麻醉师、医生未查对／对麻醉师及医生无明确查对要求，部位错误／术前未做标识。根据评估结果，制定改进措施，并于2007年1月开始实施。结果表明，该6个导致手术错误的高风险因子的事先风险数都有不同程度的下降。可见加强查对、健全风险管理制度、明确相关人员的责任、合理使用查对标识对预防手术错误是有效可行的。

Preventing Operation Error by Applying Failure Mode and Effect Analysis

Objective To identify and correct risk factors by applying Failure Mode and Effect Analysis(FMEA) and prevent operation error.Method By applying FMEA,high risk factors were measured and analyzed,and countermeasures were taken from January of 2007 to correct them.Results Six risk factors with high risk priority scores and related with potential operation failure were identified as the follows:(1)wrong patient/wrong operation patient form;(2) wrong patient / no check with ward nurses;(3)incorrect check/patient disability to express;(4) wrong operation room / picking several patients in the same time;(5)no check with anesthesiologists and doctors / no requirements for check among anesthesiologists and doctors;(6) wrong sites / no mark and signs before operation.After countermeasures were taken,the top 6 risk factors leading to operation errors were reduced.Conclusion Augmenting check,improving risk management system,identifying the responsibility of associated nurse,reasonable use of check signs are keys to preventing operation errors.