根因分析预防头颈肿瘤放疗患者鼻饲置管意外事件的效果  

Root Cause Analysis for Prevention of Nasal Feeding Catheter Accidents in Patients with Head and Neck Tumor Radiotherapy

作　　者：朱云霞[1] 黄静[1] 谢淑萍[1] 陈锃丽[1] ZHU Yunxia;HUANG Jing;XIE Shuping;CHEN Zengli(Zhejiang Cancer Hospital,Hangzhou 310022,China)

机构地区：[1]浙江省肿瘤医院

出　　处：《浙江医学教育》2019年第1期30-32,44,共4页Zhejiang Medical Education

摘　　要：目的:探索根因分析法预防头颈肿瘤放疗患者鼻饲置管意外事件的效果。方法:通过根因分析法找出可能引起头颈肿瘤放疗患者鼻饲置管意外事件发生的原因,制订床边鼻饲置管的标准化流程,进行鼻饲置管适应症的评估和风险防范策略,强化护士培训教育和医护之间的沟通,并对改进效果进行追踪。结果:2017年1-12月头颈肿瘤放疗患者鼻饲置管意外事件由2016年1-12月的9. 09%下降为零,差异有统计学意义(P <0. 05)。结论:采用根因分析法可以对头颈肿瘤放疗患者鼻饲置管的安全性进行有效评估,减少鼻饲置管意外事件的发生,从而提升护理质量。[Objective]To explore the effect of root cause analysis(RCA)in preventing nasogastric intubation accidents in patients with head and neck cancer during radiotherapy.[Method]Through RAC,the possible reasons for the accidents of intubations of nasal feeding tube in the patients with head and neck cancer during radiotherapy were found.We developed the standardized process,evaluated adaptation and risk prevention strategies in nasal feeding,and tracked the improvement effect.[Result]The accidents of intubations of nasal feeding tube in patients with head and neck cancer during radiotherapy from January to December 2016 decreased from 9.0%to 0.0%from January to December 2017.The difference was statistically significant(P<0.05).[Conclusion]The RCA can effectively evaluate the safety of intubations of nasal feeding tube in the patients with head and neck cancer during radiotherapy,and reduce the occurrence of the accidents of intubations of nasal feeding tube,so as to improve the quality of nursing.

关 键 词：头颈肿瘤患者 放疗 鼻饲置管 意外事件 根因分析法 

分 类 号：R473.73[医药卫生—护理学]