患者身份识别信息不良事件根本原因分析

文章运用根本原因分析法对2例患者身份识别的医疗信息不良事件展开分析，经过团队组成与资料收集，梳理流程并还原事件，辨识直接原因和分析根本原因，找出现有流程设计上的缺陷，针对性提出修复潜在性失误的流程改造方案。通过案例分析验证根本原因分析法是推动信息系统持续改进的有效方法；对于医疗信息不良事件，应以流程为主线展开分析，关注诊疗流程信息化后新流程各环节的安全权重分配和数据源的准确性。

Root Cause Analysis on Patients Identification with Adverse Events in the Processes Informationized

Two cases of patients identification with adverse events were reported and analyzed with the root cause analysis method.To streamline the process and reconstruct the events by collecting materials,to explore the defects of the existing process design by analyzing the proximate and root causes,to propose a process improvement plan.This paper suggests that RCA be an effective methods to continuously improve the hospital information system,RCA be applied in process analysis,the new safety weight distribution in the diagnosis and treatment processes informationized and the accuracy of the data source should be attached importance to.