采用根因分析法降低手术患者病理标本送检差错率的实践

Revising the pathological specimen delivery errors by RCA to promote patient safety in operation room

目的 :探讨根因分析(RCA)法在降低手术患者病理标本送检差错率中的作用。方法 :成立RCA小组,运用RCA法剖析导致病理标本送检差错事件的近端原因和根本原因,制定并执行改进措施。结果 :运用RCA法管理前病理标本送检差错率为1.03%,运用后病理标本送检差错率为0.26%,差错率明显降低;护士的各项能力得到提升。结论 :RCA法是管理手术室病理标本送检差错事件的有效方法,有利于护士的综合素质的提升和手术室患者安全目标的实现。

Objective：To check out the function of Root Cause Analysis in analyzing the pathological specimen delivery errors in operating room. Methods：An RCA team was set up to analyze the proximate cause and the ultimate cause of error by using the method of RCA, and then the improved measures were proposed and carried out. Results：Before using the method of RCA, the average error rate was 1.03%. After using RCA, the average error rate dropped to 0.26%;Nurse had a positive self-assessment. Conclusion：RCA is a scientiifc method in the management of pathological specimen delivery lfow. RCA method can not only improve the comprehensive ability of nurses ,but also can realize the goal of patient safety in operation room.