1例晨间集中静脉血标本采集错误的根因分析与改进

对１例晨间集中静脉血标本采集错误事件展开根本原因分析。通过原因挖掘，从建立晨间集中静脉血标本采集质量三级督导及考核机制，规范并落实晨间集中静脉血标本采集班次核查标准，以问题为导向规范护理实习生带教管理等方面加以改进，取得了较好效果。建议:患者参与患者安全管理，医务人员应加强查对制度落实并重视教学管理，医院应加强安全监管与督导，不断优化管理制度和流程。

Root Cause Analysis and Improvement of an Incident of Erroneous Collection of Venous Blood Samples in the Morning

The root cause analysis was carried out for a case of erroneous collection of venous blood in the morning.Through the cause excavation,improvements were made from aspects of establishment of a three-level supervision and assessment mechanism for the collection quality of concentrated venous blood in the morning;standardizing and implementing the inspection standard for the shift of collection of venous blood samples in the morning;taking the problem as the guidance,standardizing the teaching management of nursing interns,which achieved good results.It suggested that patients should participate in patient safety management,medical staff should strengthen the implementation of inspection system and pay attention to teaching management,hospital should strengthen safety supervision and supervision,and constantly optimize the management system and process.