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