基于参与式观察的医疗失效模式与效应分析在预防脊柱手术患者术中获得性压力性损伤的实践 [中文引用][英文引用]

目的  探讨基于参与式观察的医疗失效模式与效应分析（healthcare failure mode and effect analysis，HFMEA）在预防脊柱手术患者术中获得性压力性损伤（intraoperative acquired pressure injury，IAPI）的实践效果，为该类患者实施前瞻性护理管理提供依据。方法  形成基于参与式观察的 HFMEA 流程：确定 HFMEA 主题、组建多学科团队、绘制流程图（参与式观察）、失效模式与危害分析（危害评分矩阵及决策树分析、通过帕累托图分析主要失效原因）、改善行动和成效追踪。最终筛选出需要继续改进的 11 个高风险失效模式，其中表单 / 信息系统设计不佳、工作任务重节奏快、科室缺少规章制度、手术相关 IAPI 风险因素以及多学科团队分工不明是高风险失效模式的关键失效原因。针对关键失效原因制订一系列改善措施并实施。采用前 -后对照研究，选取 2023年 11月—2024年 4月本院的 180例脊柱手术患者作为试验组，应用基于参与式观察的 HFMEA预防流程；将 2023 年 5 月— 10 月实施原有传统预防方法的 218 例患者设为对照组。比较两组患者 IAPI 发生率和严重程度并统计试验组患者术前、术中 IAPI 风险评估完成率。结果  试验组患者 IAPI 发生率和严重程度低于对照组，差异有统计学意义（P<0.05）；其中试验组患者 178 例（98.92%）完成术前 IAPI 风险评估，172 例（95.47%）完成术中评估。结论  基于参与式观察的 HFMEA预防流程可有效降低脊柱手术患者的 IAPI 发生率和严重程度，保障患者安全，从而提升护理管理质量。

Objective To evaluate the effectiveness of a preventive workflow in participatory observation based on healthcare failure mode and effect analysis（HFMEA）in reducing intraoperative acquired pressure injury（IAPI）in patients undergoing spinal surgery，and to provide evidences for prospective nursing management. Methods A preventive workflow of participatory observationbased HFMEA was established，which included defining HFMEA topic，forming a multidisciplinary team，creating a process map（through participatory observation），conducting failure mode and hazard analysis（using a Hazard scoring matrix and decision tree analysis， and identifying the causes of key failure through Pareto chart analysis），implementing improvement actions，and tracking effectiveness. Ultimately，11 high-risk failure modes were identified for further improvement：poor design of form/information system，heavy workload and fast pace，lack of departmental regulations，risk factors of IAPI，and unclear duty and responsibility in a multidisciplinary team. A series measures for improvement were developed and implemented based on the identified key causes. A pre-and post-control study was carried out. A total of 180 patients who received spinal surgery between November and April 2024 and received traditional preventive methods were assigned to a control group. While further 218 patients who received spinal surgery between May and December 2023 were assigned to the trial group with the participatory observation on the basis of HFMEA prevention workflow. IAPI incidence rate and severity were compared between the two groups，as well as the completion rate of preoperative IAPI risk assessment in the trial group. Results The trial group demonstrated significantly lower IAPI incidence and severity compared with those in the control group（P<0.05）. In the trial group，178 patients（98.92%）completed the preoperative IAPI risk assessment，and 172 patients（95.47%）completed the intraoperative assessment. Conclusion The participatory observation based HFMEA prevention workflow can effectively reduce an incidence and severity of IAPI in patients undergoing spinal surgery，ensure patient safety and thereby enhance the quality of nursing management.