Theoretical studies using failure modes to reduce the risk of surgical position
|Keywords||failure mode and effects analysis surgical position risk control|
Objective:This study aims to construct suitable mode for medical care risk management through the probe into FMEA, and apply it to surgical position risk management, to verify whether the FMEA is suitable for the medical care and risk management inland. Reduce surgical damage and improve the patients’comfort level and the surgeons’ satisfaction by means of the clinical practice of FMEA.Methods:First confirm the common weak procedures of operating nursing through clinical research and literature analysis, then build surgical position FMEA group, and use brainstorming to analyse each sub-process to find out failure modes, potential causes and impact. Confirm high-risk sub-processes according to risk assessment based on NCPS short matrix, enter into the FMEA for RPN value, propose improvement plan for high RPN score and evaluate the results by means of clinical examination.Result:Apply FMEA to risk management in operation to find out the main cause leading to position risk:(1) surgical position management, (2) technology of medical workers, (3) preparation of auxiliary facilities and materials, (4) surgical environment, preparation, (5) value of patient status, (6) intraoperative conversion position contingency. Take appropriate intervention measures to make the surgical risks associated with the RPN position before the implementation of the 1414 total points from the dropped 350 points after the implementation, and surgical position-related injury to improve before the 12 cases, improved in 3 cases, statistics after data by the X2 test the difference was statistically significant. Patient comfort before the patient complained of discomfort in 20 cases, after the implementation of the patients complained of discomfort in 4 cases. Surgeon satisfaction degree not satisfied before the surgeon in 18 cases, surgeons are not satisfied after the implementation of zero cases, two survey data by the rank sum test was statistically significant difference.Conclusion:The application of FMEA has helped reduce the risk of surgical position and improve patient comfort and surgeon satisfaction. Although FMEA has its limitations, it is effective and feasible to reduce the risk of health care and should be promoted.