Application of healthcare failure mode and effects analysis in risk management of extracorporeal membrane oxygenation transport adverse events
10.3969/j.issn.1008-9691.2023.05.019
- VernacularTitle:医疗失效模式与效应分析在ECMO转运不良事件风险管理中的应用
- Author:
Weiying DAI
1
;
Xiangying YANG
;
Weiguo YE
;
Liuqin XIA
;
Xiaokang ZENG
;
Pei HUANG
Author Information
1. 浙江大学医学院附属杭州市第一人民医院重症医学科,浙江杭州 310006
- Keywords:
Failure mode and effect analysis;
Extracorporeal membrane oxygenation;
Transshipment;
Risk management
- From:
Chinese Journal of Integrated Traditional and Western Medicine in Intensive and Critical Care
2023;30(5):613-617
- CountryChina
- Language:Chinese
-
Abstract:
Objective To establish a project team to assess and manage the risk of out-of-town transport of extracorporeal membrane oxygenation(ECMO)patients using the healthcare failure mode and effects analysis(HFMEA),analyze the effectiveness of its application,and develop targeted improvement measures and processes.Methods Patients with ECMO who were treated in the department of intensive care unit(ICU)of Affiliated Hangzhou First People's Hospital,Zhejiang University School of Medicine March 2020 to September 2021 were selected as the study subjects.By comparing the differences in the accuracy of ECMO transport risk assessment,the rate of fixation against catheter slippage,the incidence of adverse transport events between the two groups before and after HFMEA,and the application effect of this model in ECMO transport adverse event risk management was evaluated.Results A total of 48 ECMO patients were enrolled,and 42 times of out-of-home transfers were performed,including 22 before HFMEA and 20 after HFMEA.Compared with pre-HFMEA,the accuracy of ECMO transport risk assessment[95.00%(19/20)vs.54.55%(12/22),P＜0.05]and the compliance rate of catheter slip fixation[100.00%(20/20)vs.68.18%(15/22),P＜0.05]in patients after HFMEA were significantly increased,the incidence of adverse events in transport was significantly lower[5.00%(1/20)vs.40.91%(9/22),P＜0.05].Conclusion The application of HFMEA in the risk management of ECMO transshipment adverse events is beneficial to standardize the prevention of ECMO transshipment accidents,effectively reduce the incidence of transshipment adverse events,and ensure patient safety.
