1例血小板输错事件的根本原因分析  

Root Cause Analysis of One Case of Platelet Transfusion Error

作　　者：唐新[1] 贾克刚[1] 李秀良[1] 吴允琦 董军[1] 

机构地区：[1]泰达国际心血管病医院,天津300457

出　　处：《中国卫生质量管理》2016年第2期13-15,共3页Chinese Health Quality Management

摘　　要：针对1例血小板输错事件,成立RCA团队,完成事件描述表,应用鱼骨图寻找近端原因,采用五问法剖析根本原因,制定针对性改进对策并落实,为临床安全用血提供保障。As for one case of platelet transfusion error, the team on root cause analysis （ RCA ） was established to complete events description table, fishbone diagram was used to find proximal reasons for the event. The five questions method was used to analyze root causes, and targeted improvement measures were developed and implemented, which provides effective protection on the safety of clinical blood use.

关 键 词：根本原因分析 临床用血 闭环管理 

分 类 号：R331.143[医药卫生—人体生理学]