根本原因分析法在肿瘤患者PICC非计划拔管中的应用

Root Cause Analysis of Unplanned Extubation in PICC for Cancer Patients

目的探讨根本原因分析法在肿瘤患者PICC非计划拔管中的应用效果。方法应用根本原因分析法对23例PICC非计划拔管事件进行原因分析,识别风险因素,找出根本原因,制定整改措施,并与整改措施实施后的观察组进行对比分析。结果根本原因分析法实施前后非计划拔管发生率比较差异有统计学意义,根本原因分析法实施后PICC非计划拔管率明显降低,差异有统计学意义(P<0.01)。结论根本原因分析法应用在肿瘤患者PICC非计划拔管的安全管理中,有效地降低了PICC非计划拔管的发生率,推进医疗护理质量与安全的持续改进,值得临床推广。

Objective To explore the effect of root cause analysis on unplanned extubation in PICC for cancer patients. Methods In the study, there were control group and experiment group. In experiment group, root cause analysis was conducted among 23 cases of unplanned extubation for its causes and risk factors. Root causes were found out then corrective actions were taken. Comparative analysis was conducted between two groups after corrective actions. Results The incidence of unplanned extubation reduced significantly after the implementation of root cause analysis and the difference indicated statistical significance （P〈O.01）. Conclusion Root cause analysis is effective for safety management of unplanned extubation of cancer patients, which helps to reduce the incidence of unplanned extubation and enhance nursing quality and safety.