目的 运用失效模式与效应分析(failure mode and effects analysis,FMEA)对手术室换车区工作流程进行改造,以减少手术患者错误的相关缺陷发生.方法 根据FMEA方法,成立流程改进工作小组;列出在手术室换车区护士安排手术患者的工作流程及子流程;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;跟踪整改的成效.结果 流程改进后失效模式的优先风险数值及患者错误的相关缺陷发生率显著下降,改造前后比较,差异均有统计学意义(P＜0.05).结论 FMEA作为一种风险管理工具应用于手术室换车区工作流程的改造,能前瞻性地发现流程中潜在的漏洞,充分发挥系统防御对缺陷的屏蔽功能.%Objective To improve the procedure in bed change area of operation room utilizing failure mode and effects analysis (FMEA), and to lower the deficiencies in operation room. Methods A panel of procedure improvement was established based on FMEA. Procedures and sub-procedures in bed change area of operation room were worked out and potential failure-inducing parts and reasons in each sub-procedure were identified. Results Risk priority number of failure mode and deficiency ratio were significantly lowered after the improvement (P＜0.05). Conclusion With FMEA, underlying deficiencies in procedure improvement in bed change area of operation room can be identified in advance which is beneficial to nursing quality management and improvement.
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