失效模式与效应分析在非计划性拔管中的应用

【目的】探讨应用失效模式和效应分析（FMEA）进行患者非计划性拔管的风险防范管理，以降低非计划性拔管率。【方法】采用FMEA法，成立FMEA团队；绘制流程图，进行失效模式与潜在风险原因分析，计算优先风险指数（RPN）；找出失效模式及相关原因；对需优先解决的问题进行改进。【结果】实施FMEA后，6个失效模式的RPN值均较前明显降低。患者非计划性拔管发生率由2010年的2．77％下降到2011年的0．92％，两组比较差异有统计学意义（X2=6．479，P〈0．05）。【结论】应用FMEA进行非计划性拔管防范管理，可有效降低非计划性拔管的发生率。

Application of Failure Mode and Effect Analysis in Unplanned Extubation

Objective]To explore the application of failure mode and effect analysis（FMEA） in risk prevention and management of unplanned extubation in patients in order to reduce the unplanned extubation rate. Methods] FMEA method was used to set up a FMEA team. A process flow diagram was drawn for the analysis of failure mode and potential risk reason. Priority risk index（RPN） was calculated. The failure mode and related reasons were found. The problem which should be resolved preferentially was improved. Results] Af- ter the implementation of FMEA, RPN of 6 failure modes obviously decreased in comparison with before FMEA. The incidence of unplanned extubation rate decreased from 2.77% in 2010 to 0. 92% in 2011, and there was significant difference between 2 groups（X2= 6. 479, P 〈20.05）. Conclusion] FMEA applied in pre-vention and management of unplanned extubation can effectively reduce the incidence of unplanned extubation.