摘要
目的通过应用根本原因分析法对不良事件的分析,确认根本原因,制定预防和改进方案。方法主要通过应用根本原因分析法在非计划性拔管的护理不良事件中进行调查分析。结果应用RCA后非计划性拔管率由4.3%降至1.9%。结论为预防护理不良事件发生,管理者应转变管理理念,非仅局限于对个人的责任进行追究,应从系统中寻找失误的因素,从而有利于避免类似事件的发生。
Objective Through the analysis about adverse event by root-canse analysis method, to confirm root cause and make preventive improved action. Methods By using root-cause method in unintended extubation adverse event to survey and analyze. Results After the use of RCA, the rate of unintended extubation decreased from 4. 3% to 1. 9%. Conclusions To prevent nursing accident, administrator should change management method and look for the factors for mistake in system, but not to be confined to individual responsibility.
出处
《齐齐哈尔医学院学报》
2013年第12期1835-1836,共2页
Journal of Qiqihar Medical University
关键词
根本原因分析法
非计划性拔管
不良事件
Root-cause analysis method
Unintended extubation
Adverse events
