ICU患者非计划性拔除气管插管的根本原因分析

The root cause analysis of unplanned extubation of patients in ICU

目的：通过对非计划性拔除气管插管事件的回顾性分析，探讨降低此类事件发生的应对措施。方法：组成根本原因分析（ RCA）小组，对2010年1月~2014年3月共14例ICU患者发生非计划性拔除气管插管的事件进行RCA分析，找到近端原因和根本原因。结果：系统原因是ICU非计划性拔除气管插管的根本原因。结论：改善约束材料，增加医护沟通，强化培训教育，实行预警教育，可防范ICU非计划性拔除气管插管的发生。

Objective：Patients with unplanned extubation in the ICU were analysed retrospectively to explore the mesures to prevent occurrences of the such incidents. Methods：A total of 14 patients in ICU with unexpected extubation events from January 2010 to March 2014,were analysed by the root cause analy-sis （ RCA） group to find the basic reason of the events. Results：The system fctors were the fundamental cause of the unplanned extubation in ICU patients. Conclusion：The use of appropriate binding materials,strengthen the medical communication,improve training and education and implementation of early warning education,can prevent occurrence of unplanned extubation in ICU.