1例新生儿低血糖喂糖水致心跳呼吸停止根本原因分析  

Analysis of the root cause of the cardiacand respiratory arrest caused by sugar water feeding in a hypoglycemic neonates case

作　　者：胡静[1] 陈黎丽[2] 冯祺荣[3] HU Jing;CHEN Lili;FENG Qirong(Nursing Department,Ningbo Women&Children's Hospi tal,Ningbo 315031,China;Department of Perinatal Pediatrics,Ningbo Women&Children's Hospi tal,Ningbo 315031,China;Department of Obstetrics,Ningbo Women&Children's Hospi tal,Ningbo 315031,China)

机构地区：[1]宁波市妇女儿童医院护理部,315031 [2]宁波市妇女儿童医院围产儿科,315031 [3]宁波市妇女儿童医院产科,315031

出　　处：《护理管理杂志》2020年第2期117-119,共3页Journal of Nursing Administration

摘　　要：通过根本原因分析法分析1例新生儿低血糖喂糖水致心跳呼吸停止的原因。成立根本原因分析小组,对事件进行调查,寻找近端原因,确定根本原因。提出了重新制订新生儿低血糖处理流程,规范新生儿喂养方法,在VIP病房治疗室内新增氧气瓶和负压吸引器,制订VIP病房新生儿窒息处置流程,对护理人员进行新生儿窒息复苏培训、考核,设置情景进行演练等措施,从系统和流程上改进以防止同类事件再次发生。To analyze the root cause of cardiac and respiratory arrest in a hypoglycemic neonate caused by sugar water feeding.A root cause analysis team was set up to investigate the incident,identify the cause,and develop an improvement plan.A new treatment of neonatal hypoglycemic was established,the newborn feeding method was standardized,oxygen cylinders and vacuum aspirator were equipped in the VIP ward treatment room,the neonatal asphyxia treatment process in the VIP ward was established,the nursing staff was trained and assessed in neonatal asphyxia resuscitation,and the scenarios exercises were conducted to prevent similar events occur from the aspects of system and process.

关 键 词：不良事件 根本原因分析 新生儿 低血糖 心跳呼吸停止 

分 类 号：R473.72[医药卫生—护理学]