カテーテル留置プロセスにおける故障モード影響解析

to analyze potential risks in the adult indwelling urinary catheterization process.

exploratory, descriptive and evaluative research in a teaching hospital. Working group with ten health care providers: eight nurses, one physician and one nursing technician. Activity flowchart and description built through process modeling. Potential risk analysis based on the Failure Mode and Effect Analysis method.

four sub-processes identified for the indwelling urinary catheterization process. Process review-based proactive health care risk analysis showed 55 potential failure modes, 92 potential failure causes, and 40 potential failure effects.

the method applied to review the indwelling urinary catheterization process in the hospital setting supported the proactive health care risk analysis; this issue should be further considered to contribute to the safety culture at the national level. Nurses are strategic in decision-making on health care risk management in said process, throughout catheter introduction, continuous use, and removal.