1例手术患者身份识别错误的根本原因分析

Root Cause Analysis of an identification error of a surgical patient

对1例手术患者身份识别错误事件进行根本原因分析,按照定义问题与资料收集,识别可能原因,剖析根本原因,制定并执行改善计划的步骤,完整呈现"手术患者身份识别错误"事件根本原因分析的全过程。为管理者提供质量管理的思路与方法,以便更好地识别系统中的问题,提供改善计划与预防措施。

The Root Cause Analysis method was used to analyze a case of identification error of a surgical patient.In order to reproduce the whole process of the case,the five key steps of RCA,namely defining the problem and gathering data,identifing possible causes,determining the root cause,generating plans and carrying out those plans were taken,which provided hospital managers with ideas and methods of quality management to better identify problems in the system and generate improvement plans and preventive measures.