根本原因分析法预防儿科门诊液体漏输

The use of root cause analysis in child outpatients′infusion omission management

目的减少儿科门诊液体漏输的发生,提高护理质量,确保患儿安全。方法成立质控小组,应用根本原因分析法(RCA)进行输液管理,即对儿科门诊预防液体漏输防范措施落实情况进行调查,查找根本原因,针对要因利用PDCA循环进行改进,确保各种查对及告知制度的落实,对临时续加液体加强管理,输液高峰期增加护理人力等。结果干预期门诊液体漏输率降至0,明显低于干预前。结论根本原因分析法可有效降低儿科门诊液体漏输的发生。

Objective To reduce infusion omission and improve the quality of nursing care so as to ensure children′s safety in pediatric outpatient department.Methods A quality control group was set up to manage child outpatients′infusion using root cause analysis.After investigating the precautionary measures of omission,we found the root causes and began to intervene by implementing PDCA cycle,making sure of checking and informing,strengthening the management of additional infusions and adding personnel during peak time.Results The percentage of child outpatients′infusion omission dropped to zero after the intervention.Conclusion Root cause analysis can effectively reduce the incidence of child outpatients′infusion omissions.