全麻手术患者暴露性角膜炎发生根本原因分析及预防  

Application of root cause analysis for preventing exposure keratitis for surgery patients under general anesthesia

作　　者：张志慧[1] 曾秀仪[1] 陈少兵[1] 李铭[1] 

机构地区：[1]广州市第一人民医院手术室,510180

出　　处：《广州医药》2013年第6期35-37,共3页Guangzhou Medical Journal

摘　　要：目的分析全麻手术患者暴露性角膜炎发生的根本原因,并实施有效预防措施,降低其发生率,提高眼部舒适度。方法采用根本原因分析法(root cause analysis,RCA),着眼整个手术系统和过程层面,找出导致发生暴露性角膜炎的根本原因,并采用新的眼部保护措施,比较应用RCA前后暴露性角膜炎的发生率。结果通过根本原因分析法,确定了导致暴露性角膜炎发生的根本原因,实施新的眼部保护方案后,暴露性角膜炎的发生率低于整改之前(P﹤0.05)。结论全身麻醉状态下发生暴露性角膜炎的因果关系不明确导致护理方法不对症是全麻手术患者暴露性角膜炎发生的根本原因。Objective To analysis the fundamental reason of the exposure keratitis of patients under general anesthesia, and implementing effective prevention measures in order to reduce the occurrence and improve eye comfort. Methods Using root cause analysis （root cause analysis, RCA） , establishing it in the whole operation system, to find out the fundamental causes of exposuring keratitis, and adopt new eye protection measures. Results Through the root cause analysis, we have de- termined the fundamental reason of exposure keratitis. After the implementation of the new eye protection scheme, the incidenee of exposure keratitis was obviously ]ower than before （P 〈 0. 05） . Conclusion The fundamental reason of exposure keratitis is that the indeterminate causal relationship induced the traditional exposure keratitis nursing method not suit for general anesthesia surgery patients under general anesthesia.

关 键 词：全麻 暴露性角膜炎 根本原因分析 

分 类 号：R614[医药卫生—麻醉学]