上海交通大学学报（医学版）

›› 2011, Vol. 31 ›› Issue (9): 1355-.doi: 10.3969/j.issn.1674-8115.2011.09.034

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应用医疗失效模式与效应分析降低气管插管非计划性拔管率

管咏梅, 沈南平, 何萍萍   

  1. 上海交通大学 医学院附属上海儿童医学中心心脏中心, 上海 200127
  • 出版日期:2011-09-28 发布日期:2011-09-27
  • 通讯作者: 沈南平, 电子信箱: vivianshenying@yahoo.com。
  • 作者简介:管咏梅（1969—）, 女, 副主任护师；电子信箱: gymscmc@yahoo.com.cn。

Control of unplanned endotracheal extubation with Healthcare Failure Mode and Effect Analysis

GUAN Yong-mei, SHEN Nan-ping, HE Ping-ping   

  1. Cardiac Center, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai 200127, China
  • Online:2011-09-28 Published:2011-09-27

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摘要：

目的 应用医疗失效模式与效应分析（HFMEA）改进气管插管护理流程和制度，降低气管插管非计划性拔管率。方法 应用HFMEA探讨上海交通大学医学院附属上海儿童医学中心心脏中心气管插管非计划性拔管的主要原因，改进气管插管的护理流程和制度。结果 实施改进的气管插管护理流程和制度后，非计划性气管插管拔管率由2009年的0.188降低为2010年的0.113。结论 应用HFMEA改进气管插管护理流程和制度，对医护人员进行非计划性拔管预防教育，可有效降低非计划性气管插管拔管率。

关键词: 医疗失效模式与效应分析, 气管插管, 非计划性拔管

Abstract:

Objective To improve the nursing procedure of endotracheal intubation for control of unplanned extubation with healthcare failure mode and effect analysis (HFMEA). Methods HFMEA was adopted to explore the main causes for unplanned endotracheal extubation in Cardiac Center, Shanghai Children's Medical Center affiliated to Shanghai Jiaotong University School of Medicine, and modified nursing procedure of endotracheal intubation was designed. Results After implementation of the modified nursing procedure, the unplanned endotracheal extubation rate decreased from 0.188 in 2009 to 0.113 in 2010. Conclusion Through improvement of nursing procedure of endotracheal intubation and education on medical staff on prevention of unplanned extubation with HFMEA, unplanned endotracheal extubation rate can be effectively controlled.

Key words: healthcare failure mode and effect analysis, endotracheal intubation, unplanned extubation