根本原因分析法在跌倒管理中的运用  

Application of root cause analysis in fall management

作　　者：罗晓[1] 罗莉 秦林[1] LUO Xiao;LUO Li;QIN Lin(Nursing Department,Fuling Centrer Hospital of Chongqing City,Chongqing 408099,China)

机构地区：[1]重庆市涪陵中心医院护理部,重庆408099

出　　处：《现代医药卫生》2018年第7期1004-1006,共3页Journal of Modern Medicine & Health

摘　　要：目的运用根本原因分析法分析住院患者跌倒原因并改进流程,以降低跌倒发生率。方法成立跌倒根本原因分析项目组,对某三甲医院2015年跌倒患者进行根本原因分析。从人、制度、环境、管理4个方面进行分析,根据原因分析修订跌倒风险评估量表及跌倒告知书,对护士健康教育质量进行考评,强化重点时段的人力资源配置,注重细节管理,改进工作流程后运用于2016年跌倒管理中。结果 2016年跌倒发生率[0.03%(18/56 257)]较2015年[0.06%(32/51 912)]明显降低,差异有统计学意义(χ~2=5.136,P<0.05)。2015年跌倒受伤率[96.88%(31/32)]与2016年[94.44%(17/18)]比较,差异无统计学意义(χ~2=0.170,P>0.05)。结论运用根本原因分析法分析跌倒原因并改进流程,可降低住院患者跌倒发生率,但对跌倒受伤率无明显影响。Objective To reduce the incidence of falls of inpatient by using root cause analysis and improve the proce dures.Methods Set up fall root cause analysis project team and analyze patients who fell in the hospital in 2015.This study analyzed the causes of fall of inpatient from the human,system,environment and management.The fall risk assessment scale and the fall notification were revised according to the reason analysis,What′s more,measures were taken to evaluate the quali ty of education for nurses,strengthen the allocation of human resources in key time periods and pay attention to detail manage ment.Then the improved procedures were applied to the fall management in 2016.Results The incidence of falls in 2016[0.03%(18/56 257)]was lower than that of 2015[0.06%(32/51 912)],with statistically significant difference(χ2=5.136,P<0.05).The fall injury rate had no statistical difference in 2015[96.88%(31/32)]and 2016[94.44%(17/18)](χ2=0.170,P>0.05).Conclusion The rate of fall injury is declined after using the root cause analysis to analyze the causes of falls and improving the procedures,but there is no obvious influence in fall injury rate.

关 键 词：跌倒 住院病人 护理工作 根本原因分析法 

分 类 号：R47[医药卫生—护理学]