一例全身麻醉非眼科手术患者角膜擦伤的根本原因分析与改进  

Root cause analysis and improvement of corneal abrasions in a case of non-ocular surgery patient under general anesthesia

作　　者：邢雪燕 王飞[1] 刘鑫雨 刘筱璨 郭晓慧 严思益[1] 肖博[2] 苏博兴[2] 涂淑敏 XING Xueyan;WANG Fei;LIU Xinyu;LIU Xiaocan;GUO Xiaohui;YAN Siyi;XIAO BO;SU Boxing;TU Shumin(Department of Anesthesiology,Beijing Tsinghua Changgung Hospital,School of Clinical Medicine,Tsinghua University,Beijing 102218,China;Department of Urology,Beijing Tsinghua Changgung Hospital,School of Clinical Medicine,Tsinghua University,Beijing 102218,China)

机构地区：[1]清华大学临床医学院,清华大学附属北京清华长庚医院麻醉科,北京102218 [2]清华大学临床医学院,清华大学附属北京清华长庚医院泌尿外科,北京102218

出　　处：《麻醉安全与质控》2024年第2期89-92,共4页Perioperative Safety and Quality Assurance

摘　　要：对1例全身麻醉非眼科手术患者角膜擦伤事件进行根本原因分析。按照问题定义与事件描述,识别可能原因,剖析根本原因,制定并执行改进措施的步骤,完整呈现“全身麻醉非眼科手术患者角膜擦伤”事件根本原因分析的全过程。从针对心电监护操作建立督导及考核机制,加强麻醉护理人员面罩通气手法的培训,科室规范中增加面罩通气期间的眼睛保护措施,并针对特殊手术体位的眼睛保护措施等方面加以改进,取得了较好效果。为临床管理者提供质量管理的思路与方法,以便更好地识别系统中的问题,制定针对性的改善计划与预防措施。The root cause of corneal abrasions in a case of non-ocular surgery patient under general anesthesia was analyzed.In order to present the whole process of root cause analysis(RCA)in this case,the five steps of RCA were as follows,problem definition and event description,identification of possible causes,analysis of root causes,formulation and implementation of improvements.The improvements were made in the following aspects,establishing supervision and assessment mechanism for ECG monitoring operation,strengthening the training of mask ventilation technique for nurse anesthetists,adding eye protection measures during mask ventilation and eye protection measures for special surgical position,which have achieved good results.This paper provides the ideas and methods of quality management for clinical supervisors,so as to better identify the problems in the management system and formulate targeted improvement plans and preventive measures.

关 键 词：全身麻醉 非眼科手术 角膜擦伤 根本原因分析 

分 类 号：R614.2[医药卫生—麻醉学]