Application of healthcare failure mode and effect analysis on the prevention of falls in hospitalized patients with mental disorders

Objective To reduce the incidence of psychotic inpatients fall events , improve the quality of care and ensure patient safety using healthcare failure modes and effects analysis (HFMEA). Methods According to HFMEA method, we set up anti-fall group, drew anti-fall flow chart, performed causes analysis of failure mode and potential risks, calculated risk priority number (RPN), identified critical failure modes and related causes, developed improvement programs and implemented. Results After the implementation of the HFMEA, RPN value of five key patterns were significantly lower than before(P<0.05). 0.64% fall rate before the implementation in hospitalized patients decreased to 0.28%. Conclusions It can reduce the incidence of falls and improve the quality of nursing care using the HFMEA management to perform root cause analysis and process improvement of potential failure modes of falls. Key words: Mental illness; Fall; Healthcare failure mode and effect analysis