使用故障模式和效果分析工具来改进自动停止订单流程
Ghada Hussain Al Mardawi1, Rajkumar Rajendram2,3, Arwa Balharith1
1Department of Quality Improvement, King Abdulaziz Medical City, King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia.
Global journal on quality and safety in healthcare
|November 13, 2024
概括
计算机化处方订单输入 (CPOE) 系统中的自动停止订单 (ASO) 可能导致药物错误. 故障模式和影响分析 (FMEA) 通过识别和解决ASO工作流中的潜在故障,显著降低了风险.
科学领域:
- 医疗信息学 医疗信息学
- 药物安全 药物安全
- 优化临床工作流程的优化.
背景情况:
- 计算机化处方订单输入 (CPOE) 系统中的自动停止订单 (ASO) 旨在管理治疗持续时间,潜在地改善实证抗生素等某些疗法的资源使用.
- 然而,对剂量遗漏错误的分析显示,ASOs可以在不通知处方方体的情况下不适当地终止药物,突出了关键的安全问题.
研究的目的:
- 在CPOE系统中开展质量改进计划,以确定药物ASO过程中的潜在故障.
- 开发新的工作流程并预测实施挑战,以提高药物安全性.
主要方法:
- 一个多学科团队根据卫生保健改进研究所的指导进行了故障模式和影响分析 (FMEA).
- 审查了现有的ASO工作流程,以确定故障模式,其影响和原因,并计算风险优先级号码 (RPN).
- 建议进行干预,并将新工作流程的RPN与现有工作流程进行比较.
主要成果:
- 该分析在五个工作流程步骤中确定了八种故障模式,17种影响和31种原因,高平均RPN为365.4.4.
- 开发出了具体的,可衡量的,可实现的,现实的,有时间限制的干预措施.
- 拟议的新工作流程,假设所有建议都得到执行,显示RPN显著减少 (平均117.6,p < 0.05).
结论:
- 故障模式和影响分析 (FMEA) 是在实施新流程之前识别和减轻CPOE系统潜在故障的宝贵工具.
- 积极的识别和干预可以防止药物错误,并提高药物整体安全.
- 持续的审计和监测对于确保ASO工作流程中实施的变更的持续有效性至关重要.
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