应用失效模式与效应分析防范手术室压疮的效果

目的：探讨失效模式与效应分析（FM EA ）模式预防手术室压疮的效果。方法成立 FM EA小组、进行失效模式分析、绘制流程图、找出潜在失效模式、计算危机值并制定改进措施等。比较FM EA前后各失效模式PRN值变化及手术室压疮发生率。结果手术室压疮风险管理的潜在失效模式包括术前无评估或评估不足、入室后未采取正确压疮预防措施、术中防护不当、术后防治压疮措施不得当及防范制度不完善。FM EA管理后，各失效模式的PRN值均较管理前明显降低。手术室压疮发生率显著降低，与管理前比较差异具有统计学意义（0．85％ vs 4．00％）（P＜0．05）。结论应用FMEA进行手术室压疮风险防范管理，可有效减少潜在风险，降低压疮发生率，提高护理质量。

The efficacy of failure mode and effect analysis on prevention pressure ulcers during surgery

Objective To efficacy of failure mode and effect analysis (FMEA) on prevention pressure ulcers during surgery . Methods Established FMEA team ,analyzed failure mode ,drew the flow chart ,found potential failure modes ,computed risk priori-ty number and made the improvement measures .The PRN value of failure mode and pressure ulcers during surgery rate were com-pared between before and after FMEA .Results The failure mode of risk management for pressure ulcers during surgery included preoperative non-assessment or assessment insufficient ,mishandle after into surgery room ,mishandle during operation ,postopera-tion mishandle and prevention system faultiness .After FMEA ,the PRN value of each failure mode significantly lower than before FMEA .The rate of pressure ulcers during surgery after FMEA significantly lower than before FMEA (0 .85% vs 4 .00% )(P<0 . 05) .Conclusion Using FMEA on prevention pressure ulcers during surgery ,can effectively reduce potential risk ,reduce pressure ulcers rate ,improve nursing quality .