Nagpal Kamal, Vats Amit, Ahmed Kamran, Smith Andrea B, Sevdalis Nick, Jonannsson Helgi, Vincent Charles, Moorthy Krishna
Clinical Safety Research Unit, Department of Biosurgery and Surgical Technology, Imperial College London, 10th Floor, Queen Elizabeth the Queen Mother Building, St Mary's Hospital, South Wharf Road, London W2 1NY, United Kingdom.
Arch Surg. 2010 Jun;145(6):582-8. doi: 10.1001/archsurg.2010.105.
Health care failure mode and effect analysis identifies critical processes prone to information transfer and communication failures and suggests interventions to improve these failures.
Failure mode and effect analysis.
Academic research.
A multidisciplinary team consisting of surgeons, anesthetists, nurses, and a psychologist involved in various phases of surgical care was assembled.
A flowchart of the whole process was developed. Potential failure modes were identified and evaluated using a hazard matrix score. Recommendations were determined for certain critical failure modes using a decision tree.
The process of surgical care was divided into the following 4 main phases: preoperative assessment and optimization, preprocedural teamwork, postoperative handover, and daily ward care. Most failure modes were identified in the preoperative assessment and optimization phase. Forty-one of 132 failures were classified as critical, 26 of which were sufficiently covered by current protocols. Recommendations were made for the remaining 15 failure modes.
Modified health care failure mode and effect analysis proved to be a practical approach and has been well received by clinicians. Systematic analysis by a multidisciplinary team is a useful method for detecting failure modes.
医疗保健失效模式与效应分析可识别出易于出现信息传递和沟通失败的关键流程，并提出改善这些失败情况的干预措施。
失效模式与效应分析。
学术研究。
组建了一个多学科团队，成员包括参与手术护理各个阶段的外科医生、麻醉师、护士和一名心理学家。
绘制了整个过程的流程图。使用风险矩阵评分法识别并评估潜在的失效模式。针对某些关键失效模式，使用决策树确定建议措施。
手术护理过程分为以下4个主要阶段：术前评估与优化、术前团队协作、术后交接以及日常病房护理。大多数失效模式在术前评估与优化阶段被识别出来。132例失败中有41例被归类为关键失败，其中26例已被现行方案充分涵盖。针对其余15种失效模式提出了建议措施。
改良后的医疗保健失效模式与效应分析被证明是一种实用方法，并受到临床医生的广泛认可。多学科团队进行的系统分析是检测失效模式的有效方法。
