Risk identification and intervention efficacy evaluation of hospital-acquired infections in neurosurgery department based on failure mode and effect analysis
10.19428/j.cnki.sjpm.2026.250222
- VernacularTitle:基于失效模式与效果分析的神经外科医院感染风险识别与干预效果评估
- Author:
Puyu YANG
1
;
Ye QIU
1
;
Ya YANG
2
;
Zhimin WEI
1
;
Jingru ZHAO
3
;
Weiping ZHU
1
;
Yifeng SHEN
1
;
Yuanping WANG
1
Author Information
1. Shanghai Pudong New Area Center for Disease Control and Prevention (Shanghai Pudong New Area Health Supervision Institute), Fudan University Pudong Institute of Preventive Medicine, Shanghai 200136, China
2. Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
3. Shanghai Seventh People’s Hospital, Shanghai 200137, China
- Publication Type:Journal Article
- Keywords:
hospital-acquired infection;
risk assessment;
neurosurgery department;
failure mode and effect analysis;
plan-do-check-act cycle
- From:
Shanghai Journal of Preventive Medicine
2026;38(2):159-164
- CountryChina
- Language:Chinese
-
Abstract:
ObjectiveTo establish a regional risk assessment system for hospital-acquired infections in neurosurgery department of general hospital, and to evaluate its prevention and control effectiveness. MethodsFailure mode and effect analysis (FMEA) was used to identify the core risk factors for infections in neurosurgery department. The risk priority number (RPN) of each risk factor was calculated to determine the priority intervention targets. Targeted interventions were developed and continuously refined through the plan-do-check-act (PDCA) cycles. Data from January to June 2023 (control group) and July to December 2023 (intervention group) were collected to compare the differences in environmental hygiene monitoring qualification rate, incidence rate of hospital-acquired infections among inpatients, and detection rate of bacterial antimicrobial resistance. ResultsHigh-risk factors for hospital-acquired infections in neurosurgery department included patient-related risk factors, inadequate implementation of isolation measures for special infections, and poor compliance with surgical site infection (SSI) prevention protocols. After intervention, the environmental hygiene qualification rate significantly increased from 81.55% to 100.00% (χ²=120.49, P<0.001). The overall hospital-acquired infection rate among inpatients decreased from 2.62% to 2.45%, the infection rate of per case declined from 3.12% to 2.84%, and the detection rate of multidrug-resistant organism infections reduced from 43.72% to 36.79%. Additionally, antimicrobial utilization rate decreased from 48.75% to 42.53% (χ²=34.09, P<0.001). ConclusionThe FMEA-based risk assessment system can effectively identify critical infection risks in neurosurgery department, and targeted interventions can significantly improve infection prevention and control performance.
