Alamry Ahmed, Al Owais Souzan M, Marini Abdellatif M, Al-Dorzi Hasan, Alsolamy Sami, Arabi Yaseen
From the *College of Medicine, and †College of Public Health and Health Informatics, King Saud bin Abdulaziz University for Health Sciences; and ‡Department of Quality Management, §Department of Emergency Medicine, and ∥Intensive Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
J Patient Saf. 2017 Jun;13(2):76-81. doi: 10.1097/PTS.0000000000000118.
Failure mode effect analysis (FMEA) is a proactive multistep tool used to analyze risks, identify failures before they occur, and prioritize preventive measures.
A multidisciplinary team trained on FMEA methodology analyzed the process of treatment of septic patients and recorded processes under 3 major phases (recognition of severe sepsis, referral, and resuscitation). The team identified potential failure modes in each process; assigned severity, occurrence, and detection scores for each; and calculated the risk priority numbers (RPNs). Finally, higher-priority failure modes (RPN of ≥300) were analyzed to redesign the care process.
We identified 27 processes and 48 failure modes with a mean RPN of 270. Twenty-two high-risk failures were identified by RPN of 300 or higher. All identified critical processes were related to phase 1 (recognition of sepsis) and phase 3 (resuscitation). The most critical process seemed to be related to the initial workup and treatment of septic patients, with 4 potential failure modes and a total RPN of 1485.
Patient safety and care reliability issues are a major concern in health care. This study suggests that tools such as FMEA can enable a detailed analysis of the care process of septic patients by outlining potential failure modes and guiding improvement efforts.
失效模式与效应分析（FMEA）是一种前瞻性的多步骤工具，用于分析风险、在故障发生前识别故障，并对预防措施进行优先级排序。
一个接受过FMEA方法培训的多学科团队分析了脓毒症患者的治疗过程，并记录了三个主要阶段（严重脓毒症的识别、转诊和复苏）下的流程。该团队识别了每个流程中的潜在失效模式；为每个模式分配了严重程度、发生概率和检测分数；并计算了风险优先数（RPN）。最后，对优先级较高的失效模式（RPN≥300）进行分析，以重新设计护理流程。
我们识别了27个流程和48个失效模式，平均RPN为270。通过RPN为300或更高识别出22个高风险故障。所有识别出的关键流程都与第1阶段（脓毒症的识别）和第3阶段（复苏）相关。最关键的流程似乎与脓毒症患者的初始检查和治疗有关，有4个潜在失效模式，总RPN为1485。
患者安全和护理可靠性问题是医疗保健中的主要关注点。本研究表明，FMEA等工具可以通过概述潜在失效模式并指导改进工作，对脓毒症患者的护理流程进行详细分析。
