应用根本原因分析法减少新生儿科高危药物外渗及损伤的实践

目的：探讨根本原因分析法（RCA）在减少新生儿科高危药物外渗及损伤中的作用。方法：对2011年2281例发生静脉输液高危药物外渗的案例进行根本原因分析,并制定改进措施;分析RCA实施前（2011年1-12月）与实施后（2012年1-12月）高危药物外渗发生率与程度。结果：RCA实施后高危药物外渗率及损伤率低于实施前,差异有统计学意义（P〈0.01）。结论：运用根本原因分析法能有效找到引起药物外渗及损伤的根本原因,采取相应的措施,提高新生儿科静脉输液的安全性。

The effect of Root Cause Analysis on reducing the high-risk drug exosmosis and injury in neonatal department

Objective：To explore the effect of Root Causes Analysis（RCA） on reducing the high-risk drug exosmosis and injury in neonatal department.Methods：We adopted RCA to find out the root causes of exosmosis and injury in the treatment of neonates during 2011 and draw up the corresponding corrective measures.We compared the differences of the exosmotic rate and injury extent between the year 2011（before RCA） and year 2012（after RCA）.Results：The rates of exosmosis and injury after RCA were significantly lower than those before RCA（P＆lt;0.01）.Conclusions：The application of RCA could find the root causes of exosmosis and injury.We could take effective measures to improve intravenous transfusion safety in neonatal department.