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运用失效模式与效应分析提升国际肿瘤专科医院护理采血质量

Using Failure Mode and Effects Analysis in Improving Nursing Blood Sampling at an International Specialized Cancer Center.

机构信息

King Hussein Cancer Center, Al-Jubeiha Amman, Jordan.

出版信息

Asian Pac J Cancer Prev. 2021 Apr 1;22(4):1247-1254. doi: 10.31557/APJCP.2021.22.4.1247.

Abstract

BACKGROUND

The process of blood sampling is considered one of the primary and most common nursing invasive procedures carried out daily. Any failure at any point could have a severe negative impact on patient outcomes.

PURPOSE

This project aimed to assess and improve the nursing blood sampling process in a specialized cancer center using failure mode and effect analysis (FMEA).

METHODS

An observational analytical design of the nursing blood sampling process using FMEA was conducted in King Hussein Cancer Center in Amman, Jordan. Seven steps were conducted, including a review of the blood sampling process, brainstorming potential failures, listing potential effects of each failure mode, assigning a severity rating for each potential effect, assigning a frequency/occurrence rating for each failure mode, assigning a detection rating scale for each failure mode, and calculating the Risk Priority Number (RPN) for each effect.

RESULTS

Eight (out of 28) main critical failure modes with more than 200 RPN were identified in the blood sampling process. Accordingly, five themes were developed to guide the corrective actions. These themes included: process and responsibility modifications, resource and information technology utilization, patients and family engagement, safety culture, and education and training after implementation of the corrective actions. This resulted in a 58 % reduction in the RPN of major failure modes.

CONCLUSION

Many factors lead to blood sampling errors. A critical focus should be conducted on the preparation phase due to the possible errors that may occur. Proper identification of patients and blood sample tests are the keys to a significant decrease in blood sampling errors.
.

摘要

背景

采血过程被认为是日常进行的主要且最常见的护理侵入性操作之一。任何一个环节的失误都可能对患者的结局产生严重的负面影响。

目的

本项目旨在使用失效模式与影响分析(FMEA)评估和改进约旦安曼侯赛因国王癌症中心的护理采血流程。

方法

采用 FMEA 对护理采血流程进行观察性分析设计。在约旦安曼侯赛因国王癌症中心共进行了 7 个步骤,包括审查采血流程、头脑风暴潜在的失败模式、列出每种失败模式的潜在影响、为每种潜在影响分配严重度评分、为每种失败模式分配频率/发生度评分、为每种失败模式分配检测评分以及计算每种影响的风险优先数(RPN)。

结果

在采血过程中确定了 8 个(共 28 个)主要关键失效模式,其 RPN 超过 200。因此,制定了 5 个主题来指导纠正措施。这些主题包括:流程和责任修改、资源和信息技术利用、患者和家属参与、安全文化以及实施纠正措施后的教育和培训。这导致主要失效模式的 RPN 降低了 58%。

结论

许多因素导致采血错误。由于可能发生的错误,应重点关注准备阶段。正确识别患者和血液样本检测是显著减少采血错误的关键。

https://cdn.ncbi.nlm.nih.gov/pmc/blobs/5a5b/8325149/4d9586e4d632/APJCP-22-1247-g001.jpg

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