根本原因分析法在儿科输液不良事件管理中的应用  

Application of root cause analysis in the management of pediatric transfusion adverse events

作　　者：姜玉娥[1] 熊勇[2] 杨丽[1] 郭平仙[1] 

机构地区：[1]中山市博爱医院小儿神经科,528403 [2]中山市博爱医院护理部,528403

出　　处：《中华现代护理杂志》2013年第1期79-81,共3页Chinese Journal of Modern Nursing

摘　　要：目的探讨根本原因分析法（RCA）在儿科输液不良事件管理中的应用，以改善儿科输液不良事件发生情况。方法2011年4—9月病区实施RCA前及2011年10月至2012年3月病房实施RCA后分别统计病区输液不良事件发生率、双人核对落实率及输液速度准确率。比较实施RCA前后效果。结果实施RCA后6个月输液不良事件发生率为0．03％，低于实施RCA前6个月的0．32％，差异有统计学意义（x2=19．146，P〈0．01）；实施RCA后护士双人核对落实率及输液速度准确率分别为100％，98％，均高于实施RCA前的74％，83％，差异均有统计学意义（X2分别为29．885，13．085；P〈0．01）。结论在输液不良事件管理中实施RCA能有效控制影响输液安全的主要影响因素，降低输液不良事件发生率，提高输液安全。Objective To investigate the application of root cause analysis （RCA） in the management of pediatric transfusion adverse events, in order to reduce the occurrence rate of adverse events in pediatric transfusion. Methods Root cause analysis method was used from October 2011 to March 2012. Occurrence rate of adverse events, double check and accuracy of transfusion were compared before and after the implementation of RCA. Results Six months before RCA,the occurrence rate of adverse events was 0.32% and six months after RCA was 0.03%, and the difference was statistically significant （ X2 = 19. 146, P 〈 0.01 ）. The rate of double check and accuracy of transfusion were respectively 100% and 98% after RCA, which were higher than those before RCA （74% and 83% ）, and the differences were statistically significant （ X2 = 29. 885,13. 085, respectively; P 〈 0. 01 ）. Conclusions Root cause analysis can effectively control related factors during pediatric transfusion, reduce the occurrence rate of adverse events and improve transfusion safety.

关 键 词：医院 儿科 安全管理 根本原因分析法 输液不良事件 

分 类 号：R47[医药卫生—护理学]