根本原因分析法在住院患者非计划拔管中的运用

目的探讨根本原因分析法在住院患者非计划拔管中的应用效果。方法成立根本原因分析法小组,对2017年发生的35例非计划拔管事件进行分析,收集患者非计划拔管的相关资料,采用鱼骨图找出非计划拔管事件的近端原因,确定根本原因,并拟定改进计划。实施1年后,比较应用根本原因分析法前后患者非计划拔管的情况。结果应用根本原因分析法后,住院患者非计划拔管发生率由应用前的1.28%下降至0.46%(P<0.05)。结论运用根本原因分析法能有效降低住院患者非计划拔管发生率。

Application of Root Cause Analysis in inpatient Unplanned Extubation

Objective Discuss the application effect of Root Cause Analysis(RCA)in reducing the incidence of unplanned extubation.Methods A root cause analysis(RCA)team was established to analyze 35 unplanned extubations that occured in 2017 and collect information about unplanned extubations of patients.Fishbone diagram was used to identify the proximal cause of the unplanned extubation event.After determining the root cause,an improvement plan was developed to compare the unplanned extubation of patients before and after the application of RCA.Results The incidence of unplanned extubation was in hospitalized patients decreased from 1.28%before application to 0.46%(P<0.05).Conclusion The method of root cause analysis can reduce the incidence of unplanned extubation of hospitalized patients effectively.