Table 1.
Failure mode survey of EGVB patients undergoing emergency endoscopy
| Procedure | Step 4: Hazard analysis | Step 5: Action strategy | |||||||||||
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| Main flow | Sub-flow | Failure mode | Cause of occurrence | Risk analysis | Decision tree analysis | Type of operation | Improvement plan | ||||||
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| S | IR | WTI | WTI | WTI | WTI | WTI | |||||||
| Receive patient | Poor evaluation of patients’ condition by physicians and nurses | 2A1 | Poor assessment of the condition | No procedures for diagnosis and treatment have been established | 4 | 4 | 16 | → | N | N | Y | Control | Establish the diagnosis and treatment process of esophageal and gastric varices bleeding and provide training |
| Insufficient training | 4 | 3 | 12 | → | N | N | Y | ||||||
| 2A2 | Poor management of critically ill patients | No qualified doctors were fixed for management | 4 | 4 | 16 | → | N | N | Y | Control | Uniformly manage critical patients, and fix two attending physicians to manage ICU | ||
| Receive patient | 2B1 | Poor assessment of the condition | No cluster care process has been established | 4 | 4 | 16 | → | N | N | Y | Control | Establish the cluster nursing process and special nursing emergency plan for patients with EGVB | |
| Inadequate preoperative preparation | 4 | 3 | 12 | → | N | N | Y | ||||||
| 2B2 | Inadequate training | 4 | 4 | 16 | → | N | N | Y | Control | Formulate the training program for nurses in the Department of Gastroenterology, specialized nursing workbook, specialized emergency plan and operation standard of endoscopic nursing for gastroenterology nurses | |||
| Safe transport of patient | 4C In transit | 4C | Untimely treatment of the disease during transit | Unskilled transfer process and insufficient emergency drill | 4 | 4 | 16 | → | N | N | Y | Control | Revise the process and system of patient safe transport and rehearse the emergency plan |
| Undergo emergency endoscopy | 6B Endoscopic therapy | 6B1 | No evaluation before, during and after treatment | No evaluation form has been established | 4 | 4 | 16 | → | N | N | Y | Control | Establish the evaluation list of endoscopic patients and conduct standardized evaluation before, during, and after treatment. The evaluation rate of endoscopy patients should add up to 100% |
Note: WTI: Whether to improve; S: Severity; IR: Incidence rate; EGVB: Esophagogastric variceal bleeding.