1例非机械通气患者人工气道痰液堵塞致窒息事件根本原因分析  

Root Cause Analysis of Asphyxia Caused by Sputum Blockage in Artificial Airway in a Non-Mechanical Ventilation Patient

作　　者：刘彦君 王宁丽 余新华 王静 上官红梅 师卓维 LIU Yanjun;WANG Ningli;YU Xinhua(Fourth People's Hospital of Shaanxi, Xi’an, Shaanxi, 710043, China)

机构地区：[1]陕西省第四人民医院,陕西西安710043 [2]陕西省第四人民医院院护理部大内科,陕西西安710043

出　　处：《中国卫生质量管理》2021年第11期68-71,共4页Chinese Health Quality Management

摘　　要：通过对1例非机械通气患者人工气道痰液堵塞致窒息事件进行RCA分析,确认事件发生根本原因。针对性制定并实施措施如下:完善呼吸危重症监护室人力配备及管理制度,加强医护患之间沟通与协调配合,加大医疗核心制度执行情况监管力度,规范人工气道管理,加强专科培训,制定监护病房医务人员资质管理制度等,以保证医疗护理质量安全。Root Cause Analysis(RCA)was performed on a case of asphyxia caused by sputum blockage in artificial airway of a non-mechanical ventilation patient to confirm the root cause of the event.Formulation and implementation of specific measure was as follows:to improve the staffing and management system of intensive care units for respiratory patients,to strengthen medical communication and coordination between medical staff and patients,to strengthen oversight over the implementation of core medical care systems,to standardize the management of artificial airway,to strengthen specialized training and establish the management system of medical personnel qualification in the ward,in order to ensure the quality and safety of medical care.

关 键 词：非机械通气 人工气道 痰液堵塞 根本原因分析 

分 类 号：R197.323[医药卫生—卫生事业管理]