CAJ | 학술논문

目的：探讨失效模式与效应分析（ FMEA）在降低手术患者术后留置病理标本管理失误发生率和有效控制标本送检质量中的应用。方法成立手术室FMEA团队，确立“降低术后留置病理标本管理失误发生率”为主题，依据流程分析、计算风险评估指数（ RAC）和风险优先数（ RPN）、评估结果、计划改善等程序，通过回溯过去6个月内所有术后病理标本管理失误的原因，制订相应的对策并组织实施，再进行效果检查。结果实施FMEA活动后的6个月，手术患者术后留置病理标本管理失误率从13．11％下降为0．00％。结论 FMEA活动在降低手术患者术后留置病理标本管理失误的风险中效果显著，值得应用推广。
목적：탐토실효모식여효응분석（ FMEA）재강저수술환자술후류치병리표본관리실오발생솔화유효공제표본송검질량중적응용。방법성립수술실FMEA단대，학립“강저술후류치병리표본관리실오발생솔”위주제，의거류정분석、계산풍험평고지수（ RAC）화풍험우선수（ RPN）、평고결과、계화개선등정서，통과회소과거6개월내소유술후병리표본관리실오적원인，제정상응적대책병조직실시，재진행효과검사。결과실시FMEA활동후적6개월，수술환자술후류치병리표본관리실오솔종13．11％하강위0．00％。결론 FMEA활동재강저수술환자술후류치병리표본관리실오적풍험중효과현저，치득응용추엄。
Objective To discuss failure mode and effects analysis (FMEA) in reducing the surgical patient’s postoperative indwelling pathologic specimens error rate and effective control of the specimen quality inspection application .Methods We established the FMEA team and set “reduce postoperative indwelling pathologic specimen error rate” as the theme.According to the process of drawing , analysis, calculation of risk assessment code (RAC) and risk priority number (RPN), evaluation the results, etc, we investigated all the postoperative indwelling pathologic specimen situations and analyzed the cause of error specimen lien .Then corresponding countermeasures were made and applied .At last, we checked the effect .Results After the implementation of FMEA , the postoperative indwelling pathologic specimen error rate for the surgical patients decreased from 13.11% to 0.00%.Conclusions FMEA is very effective in reducing the surgical patient ’ s postoperative indwelling pathologic specimens risk and is worthy of generalizing .