The Application Research Of Failure Mode And Effect Analysis And The “5E” Injury Prevention Strategies In Hospitalized Patients Prevention Management

Objective:The purpose of this study is to explore the application of failure mode and effect analysis in hospitalized patients fall prevention management. By investigating the current situation of the hospitalized patients falls occurred, to understand its characteristics and existing problems, and by using the FMEA to analyze the current fall prevention management process, so as to prospective find existing risks in the process, meanwhile combine with the “5E” injury prevention strategies for the prevention of falls in hospitalized patients system management process reengineering, to effectively reduce fall risk factors in hospitalized patients, and promote patient safety quality.Methods:39 cases of inpatients fall adverse event data of a tertiary level 1st class general hospital in Taiyuan from 2008 to 2013 were analyzed retrospectively, to understand the risk factors of falls in hospitalized patients, according to the method of failure mode and effects analysis, established a fall prevention management team, analyze the current prevention of falls management processes, failure mode/the reasons of potential risk and risk priority number(RPN),according to the analysis of results, combine with the WHO recommended public health injury prevention four-step process to improve the prevention of falls management processes and fall prevention quality control. Compare the RPN values, the incidence of falls in high-risk hospitalized patients after the measures have been implemented to improve with that before.Results:Through the analysis of 39 cases patients with fall related information, 53.9% of patients are older than 70 year old, secondary nursing of patients reach 84.6%, those who are accompanied with family members reach 76.9%. 74.2% occurred in the bedside and bathroom, falls occurs mainly on 4:00-6:00,7:00-8:00,20:00-21:00, the occurrence of falls are concentrated in internal medicine departments, department of psychiatry, geriatrics,respiratory totally accounted for 28.21%.Use of FMEA to screen, out six essential failure mode of fall prevention process,propose improvement measure for the analysis, and improve the management of falls prevention process. After the implementation of improvement measures, RPN value of the six critical failure modes decrease obviously, and the differences are statistically significant(p<0.05); Compare the incidence of fall for high risk patients before and after the implemention incidence of falls lowers, there are statistically significant differences(p<0.05).Conclusion:The application of FMEA quality management tool can fully exposed flaws in workflow and management, through the method of quantitative screening key failure mode,to identify the need to improve the weak link, combine with the injury prevention four steps and “5E” prevention comprehensive prevention strategy can guide managers to develop improvement measures, to strengthen the prevention of falls in hospitalized patients safety barrier, to make the management of falls prevention process standardization,scientific, and reduce the fall incidence of high risk patients, effective control of fall risk factors, as well as providing experience and method for the prevention of falls in hospitalized patients and protect patient safety.