根因分析法在急诊急救护理不良事件管理中应用的效果评价

Application of root cause analysis method in management of nursing adverse events in emergency first aid

目的 减少急诊急救护理不良事件的发生，提高护理安全。方法成立质量控制（qualitycontrol，QC）小组，运用根本原因分析法（rootcauseanalysis，RCA）分析2008年12月至2011年12月急诊急救中发生的护理不良事件近端原因与根本原因，并对根本原因提出整改措施。通过加强规章制度执行规范督查，改变护理排班模式，护士风险意识的强化教育以及加强护士的沟通技巧培训，重视日常护理工作中的细节管理等根本原因的改进。结果2012年12月进行追踪分析，急诊急救护理不良事件的发生由2011年占全院护理不良事件的9．81％下降为2012年的2．75％。结论完善相关流程与制度督查，加强护士急诊急救能力与护理危机意识培养，实行弹性排班，重视细节管理是减少急诊急救护理不良事件发生的关键所在。

Objective To reduce the occurrence of nursing adverse events in emergency first aid and improve the safety of nursing. Methods To set up the quality control （QC） team, root cause analysis （RCA） method was applied to analyze the occurrence of nursing adverse events in emergency first aid in our department from Decelnber 2008 to December 2011. Measures were produced by identifying the reasons of the proximal and the root cause. Lots of measures had been taken, such as revising the nursing working process and regime, changing the work schedule, strengthening education of nurses risk consciousness and the communication ability, paying attention to the details of daily nursing work management. Results In December 2012, nursing adverse events in our hospital was reduced from 9.81% to 2.75% in 2011. Conclusions The key point to reduce nursing adverse events in emergency first aid is to perfect nursing working process and regime, improve the ability to solve emergency first aid events and nursing crisis consciousness training, practice flexible working schedule and attach importance to the detail management.