1例CRRT枸橼酸抗凝管道连接错误事件的根本原因分析及对策

Root Cause Analysis in the CRRT citrate anticoagulant pipeline misconnection

应用根本原因分析法,对1例持续肾脏替代治疗(CRRT)枸橼酸抗凝管道连接错误的护理不良事件进行分析。根据根本原因分析的步骤,应用事件序列表、鱼骨图、五问法等管理工具,分析CRRT枸橼酸抗凝管道连接错误的根本原因并制定对策。转变管理者的管理理念,从系统层面剖析护理不良事件的根本原因,并提出改善对策与防范措施,并与大家分享,以达到更好地改进工作质量的目的。

Root Cause Analysis was used to explore reasons for citrate anticoagulant pipeline misconnection in Continuous Renal Replacement Therapy （CRRT）. The standard protocol was employed for the analysis, including table of events series, fish spine figure, and five-question method,etc.,which helped to make the analysis process more logistic and rational. The results may help administrators to change their idea, analyze adverse event systematically, and pave the way for further strategies of modification and prevention.