运用根源分析法调查导管相关性血流感染暴发事件  

Investigation of catheter-related blood stream infection outbreak with root-cause analysis method

作　　者：王豪[1] 刘丁[1] 陈萍[1] 方清永[1] 黄庆宁[1] 王政[1] 南玲[1] 成瑶[1] 

机构地区：[1]第三军医大学第三附属医院野战外科研究所重庆市医院感染控制中心,重庆400042

出　　处：《中华医院感染学杂志》2012年第14期3044-3046,共3页Chinese Journal of Nosocomiology

摘　　要：目的分析一起导管相关性血流感染暴发事件的根本原因,并以此为依据,有效减少血流感染暴发事件的发生。方法采用根源分析法(RCA)对该起血流感染暴发事件进行分析并持续改进。结果在确认近端原因后,对其进行了随机病例对照研究(RCT),患者免疫力低下的OR值为0.12,95%CI为1.59～4.77,未选择氯己定进行皮肤消毒的OR值为0.94,95%CI为6.78～12.31,留置时间>7d的OR值为1.23,95%CI为3.76～10.52,使用肝素进行封管的OR值为2.33,95%CI为5.17～9.29;封管液的污染是导致此次暴发的根本原因。结论实施联动措施能有效减少导管相关性血流感染的发生;使用RCA能有效减少医疗不良事件发生,特别能减少医院感染暴发事件。OBJECTIVE To analyze the outbreak of catheter-related blood stream infections,based on the evidence,to effectively reduce the incidence of the blood stream infections.METHODS We used root-cause analysis to investigate the outbreak of catheter-related blood stream infections.RESULTS After the recognition of the proximal causes,we conducted randomized controlled trial for the proximal causes.OR of patients with low immunity was 0.12,95%CI 1.59-4.77;OR of not choosing chlorhexidine for skin disinfection was 0.94,95%CI 6.78～12.31;OR of retention time more than 7 days was 1.23,95%CI 3.76-10.52;OR of sealed tube with heparin was 2.33,95%CI 5.17-9.29;the contaminated sealing solution was the root cause of the outbreak.CONCLUSION To enforce the bundle care can effectually reduce the incidence of catheter-related blood stream infections;the application of RCA can effectively reduce the adverse medical incidents,the outbreaks of nosocomial infections in particularly.

关 键 词：导管相关性血流感染 暴发 根源分析 

分 类 号：R181.32[医药卫生—流行病学]