基于RCA的手术纱布清点不良事件改进效果研究  

The Improvement Effect of Surgical Gauze Counting Adverse Events Based on Root Cause Analysis

作　　者：李俊杰 张琳娟[1] 梅娜[1] 罗嘉婷 LI Junjie;ZHANG Linjuan;MEI Na(The First Affiliated Hospital of Xi'an Jiaotong University,Xi'an,Shaanxi,710061,China;不详)

机构地区：[1]西安交通大学第一附属医院,陕西西安710061

出　　处：《中国卫生质量管理》2024年第7期67-71,共5页Chinese Health Quality Management

基　　金：陕西省重点研发计划“基于3D人脸识别技术的日间手术安全核查系统设计及应用研究”(编号:2023-YBGY-145)。

摘　　要：目的探讨根本原因分析法(RCA)在手术纱布清点不良事件中的应用效果。方法组建RCA小组,回溯事件经过并使用时间序列表整理资料,找出近端原因后采用改良原因树图分析根本原因,通过屏障分析、拟订行动计划,最终组织实施并长期监测持续改进效果。结果改进后术后纱布入袋执行率、自然腔道手术物品清点率、台上小纱布定点放置执行率、保洁人员垃圾袋不叠套执行率明显上升(P<0.05),为医务部提供了接台时间检查基线(5 min),并研发了一种可以识别纱布一致性的清点设备。结论应用RCA进行手术纱布清点不良事件分析,能够更加清晰地识别手术室纱布清点流程中的系统缺陷并针对性改进,从而有效规避护理风险,保障患者安全。Objective To explore the application effect of root cause analysis(RCA)in counting adverse events of surgical gauze.Methods The RCA team was established to trace the event process,and use a time series table to organize data.After identifying the proximal cause,an improved causal tree was used to analyze the root causes.Through barrier analysis,the formulation and ultimately implementation of action plans,long-term monitoring of continuous improvement effects was carried out.Results After the improvement,the implementation rate of gauze into the bag,the inventory rate of natural cavity surgical items,the fixed-point placement rate of small gauze on the stage,and the non-stacking implementation rate of cleaning garbage bags increased significantly(P<0.05).The baseline of pick-up time for the medical department(5 minutes)was provided,and a kind of counting equipment which can identify the consistency of gauze was developed.Conclusion The application of RCA in the analysis of adverse events of surgical gauze counting can more clearly identify the system defects in the gauze counting process in the operating room and make targeted improvements,so as to effectively avoid nursing risks and ensure patient safety.

关 键 词：根本原因分析法 手术室 物品清点 不良事件 患者安全 

分 类 号：R197.32[医药卫生—卫生事业管理]