根本原因分析及行动法在完善无陪病房患儿身份识别中的应用研究  

Application of root cause analysis and action method in improving the identification of children in non-accompanying ward

作　　者：童孝笑 张红梅 游丽霞 周琦瑛 TONG Xiaoxiao;ZHANG Hongmei;YOU Lixia;ZHOU Qiying(Department of Neonatology,Hangzhou Children's Hospital,Hangzhou 310014,China)

机构地区：[1]杭州市儿童医院新生儿科,310014

出　　处：《护理管理杂志》2020年第8期601-604,共4页Journal of Nursing Administration

摘　　要：目的探讨在发生不良事件后运用根本原因分析及行动法的应用价值。方法通过结合临床实际案例,组建根本原因分析行动小组,还原事件的经过,分析并判断事件的性质,确认事件发生的根本原因,然后拟订改善计划并落实,最后检验根本原因分析及行动法开展后取得的成效。结果运用根本原因分析及行动法规范流程,完善了信息漏洞;降低了无陪病房患儿身份识别错误的发生率,提高了护理安全质量;全员参与改进措施,强化了医疗团队的协作关系。结论运用根本原因分析及行动法质量管理工具,不断优化流程和规范,能有效规避护理不良事件的发生。Objective To explore the effect of root cause analysis and action(RCA2)in improving the identification of children in non-accompanying ward.Methods The RCA team was set up according to clinic case,and measures were established including restoring the process of the incident,judging its nature and confirming the root cause of the incident.Then conducted the improvement plan,and evaluated its effect.Results RCA2 standardized the process,improved the information loopholes,reduced the incidence of children's identification errors in non-accompanying ward,improved nursing safety,strengthened the cooperation of the medical team.Conclusion The application of RCA2 quality management tool to optimize the process and norms continuously,can effectively avoid the occurrence of nursing adverse events.

关 键 词：根本原因分析及行动法 不良事件 安全管理 新生儿 身份识别 

分 类 号：R473.72[医药卫生—护理学] C931.2[医药卫生—临床医学]