摘要
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.
作者
张琦
秦薇
张玉侠
ZHANG Qi;QIN Wei;ZHANG Yuxia(Nursing Department of Zhongshan Hospital,Fudan University,Shanghai,200032,China)
出处
《中国护理管理》
CSCD
北大核心
2020年第1期54-57,共4页
Chinese Nursing Management
基金
复旦大学双一流建设项目(2018-40-22)
上海市护理学会2019年优秀青年人才育苗计划.
关键词
根本原因分析
身份识别
患者安全
Root Cause Analysis
identification
patient safety