根本原因分析(RCA)在护理不良事件分析中的临床应用研究

目的探讨根本原因分析(RCA)在护理不良事件分析中的临床应用方法和效果。方法建立安全管理小组,对护理人员进行培训,运用RCA,将我院主动上报的45例不良事件进行分析,搜集相关资料,找出近端原因,确认根本原因,制订和执行整改措施。并与组建安全管理小组前本院不良事件上报率进行对比。结果组建安全管理小组前本院护理不良事件上报31件,据调查实际发生63件,上报率为49%;组建安全管理小组后,本院护理不良事件上报45件,据调查实际发生是56件,上报率为80.4%;本院实际发生数降低,上报率比较,差异有统计学意义(P<0.01)。结论 RCA是分析护理不良事件、提高护理安全质量的有效管理工具。

The Nursing Adverse Event of Root Cause Analysis for Clinical Application Study

Objective To study the clinical methods and effects of RCA(root cause analysis) in the analysis of nursing adverse events.Methods Establish safety management groups,and nursing personnel training,the use of RCA,our hospital from active reported adverse events in 45 cases were analysed,collecting relevant material,and find out the proximal reason and confirm the root cause,formulate and implement the corrective measures.And with a safety management team reported adverse events before the rate are compared.Results To establish a safety management group nursing adverse events before our report and the survey actually occurred is 63 cases,and only 49% reported rate;After a safety management team,we care adverse events reported 45 case,the survey actually occurred is 56 cases,report rate is 80.4%;We actually occurred several reduce,report rate increase,a statistically significant difference(P<0.01).Conclusion RCA is the effective management tool to analysis nursing adverse events and to improve the nursing quality of safety.