根因分析法在住院患者防跌倒管理中的应用

The application of root cause analysis in tumbling prevention management for the hospitalized patients

目的:探讨根因分析法(RCA)在住院患者防跌倒管理中的应用效果。方法:成立RCA管理小组,对2011年住院患者跌倒问题采用RCA法进行根本原因分析,结合临床实际,制定预防跌倒的防范措施,并与2012年跌倒发生率比较。结果:2012年有6例住院患者发生跌倒,跌倒发生率为0.14‰,较2011年的17例(跌倒发生率为0.49‰)明显下降。结论:应用根因分析法,可有效预防住院患者跌倒的发生,改善护理服务质量。

[ Objective] To explore the effect of Root Cause Analysis （RCA） used in tumbling prevention management for the hospitalized patients. [ Method] RCA management group was established and the causations of inpatients fall problem in 2011 were analyzed with RCA combined with clinical practice to develop preventive nursing measures , and then compared with the fall incidence in 2012. [Result]6 cases of hospitalized patients accidental falls occurred in 2012 （ the tumbling rate was 0.14 %0）, and there were 17 cases in 2011 （tumbling rate was 0.49%.）. [ Conclusion] Application of Root Cause Analysis can be effective in preventing inpatients＇ accidental falls, so as to improve the quality of nursing service.