RCA分析法在婴幼儿静脉留置针绷带固定引起压疮中的应用  

RCA analysis In infant venous indwelling needle bandage fixed cause the application of pressure ulcers

作　　者：辛翠娟[1] 王洪[1] 高永梅[1] 陈麒羽[2] 

机构地区：[1]吉林大学第一医院小儿神经血液护理平台,吉林省长春市130021 [2]吉林大学第一医院神经血管外科,吉林省长春市130021

出　　处：《中国组织工程研究》2014年第B05期132-133,共2页Chinese Journal of Tissue Engineering Research

摘　　要：目的：运用RCA分析法，找出婴幼儿静脉留置针绷带固定引起压疮的根本原因制定整改措施。方法：对发生静脉留置针绷带固定引起压疮的患儿临床资料采用RCA分析，找出近端原因，确定根本原因。结果：造成静脉留置针绷带固定引起压疮的根本原因是护理人员主动服务意识不强，人力资源配备不足。责任护士健康教育不到位，专业知识水平掌握不够，对高危患者无风险管理意识等因素造成的。结论：采用RCA分析能准确找出不良事件的根本原因，可以有效的预防再次发生类似事件。Using RCA analysis method, find out the root cause of fixed pressure ulcers of infant venous indwel ing needle bandage formulate rectification measures. On the occurrence of venous indwel ing needle bandage caused the clinical data were analyzed by RCA to find the pressure ulcer, proximal cause, determine the root cause. The root cause of venous indwel ing needle fixed pressure ulcers bandage is nursing staff initiative service consciousness is not strong, lack of human resources. Responsibility nurse health education is not in place, not enough professional knowledge level master, factors causing no awareness of risk management for high-risk patients. RCA analysis can accurately identify the root causes of adverse events, which can effectively prevent the recurrence of similar incidents.

关 键 词：RCA分析 婴幼儿 压疮 

分 类 号：R472.9[医药卫生—护理学]