运用根原因分析及行动法改善压脉带长时间未松事件
|
摘要
通过在科室不良事件分析中运用根原因分析及行动法(RCA2),使每个护理人员意识到不良事件发生的环节、部位及改进的空间,避免相关不良事件的再次发生,同时激发创新思维。全员参与改进措施,提高活动效率和成果有效性,提升科室安全管理的质量。本文结合临床实际案例,具体阐述根原因分析及行动法的开展和取得的成效。
Using Root Cause Analysis and Actions(RCA2) method in the analysis of adverse events in hospital departments, we aim to make every caregiver aware of the step, section of adverse events and corresponding improvement potential, in order to avoid the recurrence of related adverse events and stimulate innovative thinking. Full participation in improvement measures was applied to improve the efficiency of activities and effectiveness of results, and also improve the quality of department safety management. Combining with clinical practical cases, this paper expounded the development of the RCA2 method and the results obtained.
Using Root Cause Analysis and Actions(RCA2) method in the analysis of adverse events in hospital departments, we aim to make every caregiver aware of the step, section of adverse events and corresponding improvement potential, in order to avoid the recurrence of related adverse events and stimulate innovative thinking. Full participation in improvement measures was applied to improve the efficiency of activities and effectiveness of results, and also improve the quality of department safety management. Combining with clinical practical cases, this paper expounded the development of the RCA2 method and the results obtained.
引文
1 Bagian JP,Gosbee J,Lee CZ,et al.The Veterans Affairs root cause analysis system in action[J].The Joint Commission journal on quality improvement,2002,28(10):531-545.
2张伟,徐玉芝,张继芝,等.RCA2在护理不良事件分析中的应用[J].中国护理管理,2017,17(10):1379-1383.
3林菊芳,张会妙.根本原因分析法在护理安全管理中的应用[J].赣南医学院学报,2015,35(3):458-459,461.
4黄婷婷,李艳双,焦明丽,等.采用根因分析法降低手术患者病理标本送检差错率的实践[J].中国护理管理,2015,15(4):471-474.
5罗蔼,陆新容,徐飞华.根本原因分析法在74例用药错误分析中的应用[J].现代医药卫生,2015,31(z1):66-68.
6 van der Starre C,van Dijk M,van den Bos A,et al.Paediatric critical incident analysis:lessons learnt on analysis,recommendations and implementation[J].European journal of pediatrics,2014,173(11):1449-1457.
2张伟,徐玉芝,张继芝,等.RCA2在护理不良事件分析中的应用[J].中国护理管理,2017,17(10):1379-1383.
3林菊芳,张会妙.根本原因分析法在护理安全管理中的应用[J].赣南医学院学报,2015,35(3):458-459,461.
4黄婷婷,李艳双,焦明丽,等.采用根因分析法降低手术患者病理标本送检差错率的实践[J].中国护理管理,2015,15(4):471-474.
5罗蔼,陆新容,徐飞华.根本原因分析法在74例用药错误分析中的应用[J].现代医药卫生,2015,31(z1):66-68.
6 van der Starre C,van Dijk M,van den Bos A,et al.Paediatric critical incident analysis:lessons learnt on analysis,recommendations and implementation[J].European journal of pediatrics,2014,173(11):1449-1457.