RCA2在1例非计划性气管拔管事件中的应用  

Application of root cause analysis in a case of unplanned extubation

作　　者：周宁宁 应嘉 孙建良 程远 ZHOU Ningning;YING Jia;SUN Jianliang;CHENG Yuan(Operation Room,Hangzhou First People s Hospital Affiliated to Nanjing Medical University,Hangzhou 310006,China;Department of Anesthesiology,Hangzhou First People s Hospital Affiliated to Nanjing Medical University,Hangzhou 310006,China)

机构地区：[1]杭州市第一人民医院,南京医科大学附属杭州医院手术室,浙江杭州310006 [2]杭州市第一人民医院,南京医科大学附属杭州医院麻醉科,浙江杭州310006

出　　处：《麻醉安全与质控》2018年第2期87-90,共4页Perioperative Safety and Quality Assurance

基　　金：浙江省中医药科技计划(2013ZB099);杭州市卫计委重点项目(2014Z05)

摘　　要：目的通过对1例非计划性气管拔管事件的分析,介绍在根本原因分析法(RCA)基础上的RCA^2在医院手术室及麻醉科中的应用。方法运用根本原因分析法回顾性分析杭州市第一人民医院1例非计划性气管拔管事件。结果通过一系列的分析找出事件发生的各种末端原因并确定根本原因,采取了制订并落实转床流程、进行气管导管固定培训、添置转运呼吸机等整改措施,并对整改效果进行评价。结论 RCA^2为医院手术室、麻醉科提供了一种科学系统地处理差错的方法,值得在临床工作中推广。Objective RCA2 was applied to solve the problems in the operation room and department of anesthesiology through the analysis and action of a case of unplanned extubation.MethodsA case of unplanned extubation in the operation room was analysed by using the RCA2,a root cause analysis plus action technique.Results The main causes leading to this error was uncovered and a series of rectification measures was adopted.These measures included development of the bedexchange system,systemic training of surgical and nursing staffs on tracheal tube fixation,and use of transportable ventilator.We verified the positive effect of these rectification measures.Conclusion The RCA2 is a scientificallysolid and clinicallyuseful method.RCA2 is worth promoting in the problemsolving process in clinical arena.

关 键 词：根本原因分析 RCA2 非计划性气管拔管 转床流程 

分 类 号：R614[医药卫生—麻醉学]