1例医院相关性VTE事件的根因分析  

Root Cause Analysis of a Hospital-Related VTE Event

作　　者：夏磊[1] 应娇茜[1] 张燕[1] 张佳丽[1] 甘亢 刘文婷[1] 李静[2] XIA Lei;YING Jiaoqian;ZHANG Yan(China-Japan Friendship Hospital,Beijing,100029,China;不详)

机构地区：[1]中日友好医院,北京100029 [2]中日友好医院医务处,北京100029

出　　处：《中国卫生质量管理》2020年第5期72-75,155,共5页Chinese Health Quality Management

基　　金：基于FOCUS-PDCA的院内VTE防治管理体系的重构及效果评价(中日友好医院院级科研基金项目,项目编号:2018-2-GL-5)。

摘　　要：组建RCA团队,回顾性分析1例医院相关性VTE事件发生过程,对事件根本原因进行剖析,从明确防治流程、开展分层次培训与考核、加强质量控制等方面进行改进,使VTE风险评估率、出血风险评估率、预防措施实施率显著提升,致死性PTE发生率显著下降。The RCA team was formed to retrospectively analyze a case of hospital-related VTE for the root causes.Improvement was made from aspects of clarifying the control process,carrying out hierarchical training and assessment,and strengthening quality control,which significantly increased the rate of VTE risk assessment,the rate of bleeding risk assessment and the implementation rate of preventive measures,and significantly reduced the incidence of fatal PTE.

关 键 词：医院相关性VTE(HA-VTE) 肺血栓栓塞症(PTE) 根因分析(RCA) 患者安全 

分 类 号：R197.323[医药卫生—卫生事业管理] R543[医药卫生—公共卫生与预防医学]