RCA在心内科服用安眠药者跌倒或坠床事件中的应用  

Application of RCA in prevention of tumbling or falling down from bed in patients who take sleeping pills in Department of Cardiology

作　　者：张飞娟 黄饶英[2] 陈毅文[2] ZHANG Feijuan;HUANG Raoying;CHEN Yiwen(Department of Cardiology;Nursing Department,Xiamen Second Hospital,Xiamen,Fujian 351021,China)

机构地区：[1]厦门市第二医院心内科,福建厦门351021 [2]厦门市第二医院护理部,福建厦门351021

出　　处：《现代临床医学》2018年第5期334-336,共3页Journal of Modern Clinical Medicine

摘　　要：目的:探讨根本原因分析法(RCA)对预防服用安眠药患者发生跌倒或坠床事件的效果。方法:根据现实的案例(服用安眠药后的住院患者发生坠床事件导致患者蛛网膜下腔出血)应用RCA进行案例分析,找出根本原因,制定改进措施并实施。结果:应用RCA系统分析改进后,2016年5月至2017年4月心内科服用安眠药的住院患者中,未发生跌倒或坠床事件;并由此形成心内科服用安眠药患者跌倒或坠床的管理规范。结论:应用RCA能有效找到事件的根本原因,采取相应的改善行动,并分享案例改进方法,大大减少类似事件的发生,提高护理工作质量,保障患者安全。Objective： To discuss the effect of root cause analysis （RCA） in the prevention of the occurrence of tumbling or falling down from bed in patients who take sleeping pills in Department of Cardiology. Methods： RCA was used to analyze a real case in which a hospitalized patient suffered from subarachnoid hemorrhage because of falling down from bed after taking sleeping pills. And then the primary cause of falling down from bed was found and improvement measurements were drawn up and carded out. Results： After the analysis and improvement by RCA, no hospitalized patient who took sleeping pills fell from bed in Department of Cardiology from May 2016 to April 2017. The standard of management of hospitalized patients who took sleeping pills in Department of Cardiology was formulated during the same period. Conclusion： It is effective for us to find out the root cause of an incident by using RCA. We can take con＇esponding ameliorative measurement and share it to other nurses to reduce the occurrence of such incident so that the quality of nursing service can be improved and the safety of patient can be guaranteed.

关 键 词：根本原因分析法 跌倒 坠床 安眠药 

分 类 号：R473.5[医药卫生—护理学]