护理不良事件持续改进的成效  

Effects of Root Cause Analysis Method Applied in the Continuous Reduction of Nursing Adverse Events

作　　者：乔安花[1] 彭飞[1] 杨亚娟[1] 王芳[1] 袁旭 QIAO Anhua,PENG Fei,YANG Yajuan,WANG Fang,YUAN Xu(Department of Nursing,Changzheng Hospital, Second Military Medical University, Shanghai 20000)

机构地区：[1]第二军医大学附属长征医院护理部,上海200003

出　　处：《解放军医院管理杂志》2018年第3期279-282,290,共5页Hospital Administration Journal of Chinese People's Liberation Army

摘　　要：目的评价根本原因分析法(root cause analysis,RCA)在护理不良事件持续改进中的成效与作用,减少护理不良事件的发生,提高护理安全。方法成立根本原因分析小组,运用根本原因分析法分析2015年1—12月医院发生的护理不良事件根本原因,并对根本原因提出整改措施,落实改进措施。结果改进措施落实后,护理不良事件总体发生率由2015年的0.27‰降低至2016年的0.12‰,护理安全隐患上报率由2015年的3.6‰提升至2016年的4.5‰,差异具有统计学意义(P<0.05)。结论根本原因分析法可以降低护理不良事件发生率,确保患者安全。To evaluate the effects and functions of root cause analysis （RCA） in the continu-ous reduction of nursing adverse events and to improve the safety of nursing care. Methods The root analysis team was established and the root causes of adverse events in a hospital from January to December in 2015 were ana-lyzed. A number of rectification measures were proposed and applied accordingly. Results After the implementa-tion of the rectification measures, the incidence of nursing adverse events in the hospital declined from 0. 21 %c in2015 to 0. 12%c in 2016, and the reporting rate of nursing safety hazard increased from 3.6%o in 2015 to 4. 5%o in2016 （P 〈0. 05） . Conclusion Root cause analysis can help reduce the incidence of nursing adverse events and ensure the safety of patients.

关 键 词：不良事件 护理安全管理 根本原因分析 

分 类 号：R197.32[医药卫生—卫生事业管理]