Application of health failure mode and effect analysis in the prevention of pressure sore in spine surgery patient

Objective:To explore the effects of health failure mode and effect analysis(HFMEA) on the prevention of pressure sore in spine surgery patients.Methods:The formation of HFMEA group of pressure sore in patients with spinal surgery in prone position was established,the reason of sore in the patients treated with spine surgery in prone position were analyzed between October 2014 and March 2015.The basic reasons of sore were identified by finding out the risk factors of need intervention,calculating the RPN and drawing the flow diagram of risk prevention of pressure sores,which was used to list the improvement failure mode,formulate,organize and implement the action plan.The RPN was compared before and after implementing HFMEA.Results:The RPN of failure mode significantly decreased after improving the flow diagram(P<0.01).Six cases with pressure sores before improvement and no case with pressure sore after improvement were found,the difference of which was statistically significant(P<0.05).Conclusions:The application of HFMEA in cause analysis and process improvement in prone position patient with spine surgery can effectively prevent pressure sore,and improve the nursing quality in operation.