基于HFMEA构建妇幼专科医院静脉用药安全护理防控体系的实践研究

Practical Research on Constructing a Safety Nursing and Prevention System for Intravenous Medication in Maternal and Child Specialized Hospitals Based on HFMEA

摘要: 目的：探讨医疗失效模式与效应分析(HFMEA)在妇幼专科医院静脉用药安全管理中的应用效果，构建一套前瞻性、系统化的护理防控体系。方法：组建品管圈团队，运用HFMEA方法，系统梳理静脉用药流程，识别潜在失效模式并进行风险评估，针对高风险环节制定并实施综合改进措施。比较体系实施前后的风险优先指数(RPN)、用药不良事件发生率及护士安全行为依从率。结果：实施基于HFMEA构建的防控体系后，静脉用药流程中关键环节的RPN值显著下降，用药不良事件发生率由实施前的25.7%降低至5%以下，护士在双人核对，高危药品管理等核心安全行为的依从率提升至98%以上。结论：基于HFMEA构建的静脉用药安全护理防控体系，能将管理重点从事后处理转向事前预防，有效识别并阻断妇幼静脉用药中的高风险环节，显著提升用药安全与护理管理质量。

Abstract: Objective: To explore the application effect of Medical Failure Mode and Effects Analysis (HFMEA) in the safety management of intravenous medication in women’s and children’s specialized hospitals, and to construct a forward-looking and systematic nursing prevention and control system. Method: Establish a quality control team, use the HFMEA method to systematically streamline the intravenous medication process, identify potential failure modes and conduct risk assessments, and develop and implement comprehensive improvement measures for high-risk areas. Compare the risk priority index (RPN), incidence of adverse drug events, and compliance rate of nurse safety behavior before and after the implementation of the system. Result: After implementing the prevention and control system based on HFMEA, the RPN value of key links in the intravenous medication process significantly decreased, the incidence of adverse drug events decreased from 25.7% before implementation to below 5%, and the compliance rate of nurses in core safety behaviors such as double checking and high-risk drug management increased to over 98%. Conclusion: The safety nursing and prevention system for intravenous medication based on HFMEA can shift the focus of management from post-treatment to pre prevention, effectively identify and block high-risk links in maternal and child intravenous medication, and significantly improve medication safety and nursing management quality.