根因分析法对1例PICC导管接头滑脱移位至心脏的分析及改进  

Root cause analysis and improvement of 1 case of PICC catheter adapter slippage to the heart

作　　者：王田芳[1] 赵芳芳 

机构地区：[1]西安市中心医院消化科,陕西西安710003

出　　处：《临床医学研究与实践》2018年第2期86-87,共2页Clinical Research and Practice

摘　　要：目的应用根因分析法(RCA)分析1例PICC导管接头滑脱移位至心脏的原因,并提出整改措施。方法运用根因分析法分析1例治疗间歇期出现PICC导管接头滑脱并移位至心脏的原因。结果该患者经介入治疗,取出导管,1周后出院。针对原因,进一步提出整改措施,后面无此类事件发生。结论肿瘤患者行PICC置管化学治疗中,治疗间歇期导管的维护及并发症的预防对PICC置管患者至关重要,需要予以密切关注,避免不良事件发生。Objective To analyze the causes of 1 case of PICC catheter adapter slippage to the heart by root causeanalysis （RCA） and put forward some corrective measures. Methods RCA was used to analyze the causes of a case ofslippage of PICC catheter adapter to the heart in the therapy interval. Results The patient was given intervention treatment,removed the catheter and released from the hospital a week later. Then corrective measures were put forward according tothe causes, no such incidents occurred. Conclusion For tumor patients with PICC catheter during chemical treatment, inthe therapy intervals, maintenance of catheter and prevention of complications are major things, which need to be givenmore attention to avoid incidence of adverse events.

关 键 词：PICC导管 脱落 心脏 介入 根因分析(RCA) 

分 类 号：R473[医药卫生—护理学]