运用根源分析法调查输液发热反应事件  

Investigation of pyrogenic reaction induced by transfusion with root-cause analysis method

作　　者：索瑶[1] 范珊红[2] 李颖[2] 许文[2] 戈伟[2] 慕彩妮[2] 张峰[3] 

机构地区：[1]西安交通大学医学院第二附属医院感染管理科,陕西西安710004 [2]第四军医大学唐都医院感染管理科,陕西西安710038 [3]西安市疾病预防控制中心卫生监测科,陕西西安710054

出　　处：《中华医院感染学杂志》2013年第7期1602-1604,共3页Chinese Journal of Nosocomiology

摘　　要：目的分析一起输液反应暴发事件的根本原因,据此进行相应医疗质量改进,有效减少输液反应事件再次发生。方法运用根源分析法(RCA),结合鱼骨图,找出输液反应事件发生的远端和近端原因,同时运用病例对照研究,找出该次事件发生的根本原因。结果在确定了远端和近端原因后,对近端原因进行病例对照研究显示,冲管与封管操作不规范的OR值为3.500,95%CI为1.780～6.883;留置针穿刺非一次性成功的OR值为2.333,95%CI为1.424～3.823;A-C-L导管维护不规范是导致此次输液反应事件发生的根本原因。结论输液反应的发生一般是多种因素共同作用的结果,而非单一因素所致,应用根源分析法可有效减少医疗不良事件发生,对于该次输液反应事件,在全院实行严格的岗前培训和考核制度后,再无类似事件发生。OBJECTIVE To analyze the fundamental causes of pyrogenic reaction induced by transfusion in one cases and improve the healthcare quality based on the evidence so as to effectively reduce the incidence of the pyrogenic reaction induced by transfusion. METHODS The root-cause analysis （RCA） method combined with fishbone diagram was used to find the proximal causes and distal causes, and a case-control study was carried out to explore the fundamental causes of the pyrogenic reaction induced by transfusion. RESULTS After the recognition of the proximal causes and distal causes, a case-control study was conducted for the proximal causes. The OR of non- standard operation of infusing and locking the peripheral intravenous catheter was 3. 500 （95 %CI： 1. 780-6. 883） OR of successfully pricked venous indwelling needle more than one time was 2. 333 （95MCI： 1. 424-3. 823）. Non- standard operation of infusing and locking the peripheral intravenous catheter was the root cause of the pyrogenic reaction induced by transfusion. CONCLUSION The incidence of transfusion reactions is not caused by a single fac- tor but is under the comhined effect of multiple factors ~ the application of root-cause analysis can effectually reduce the adverse medical incidents. There is no similar incident after the pre-assignment training and check-up system are adopted in the whole hospital.

关 键 词：输液发热反应 原因 根源分析 

分 类 号：R181.32[医药卫生—流行病学]