根因分析法预防老年外科高危患者各类留置管道非计划性拔管的效果

Effect of Root Cause Analysis in the Prevention of Unplanned Extubation in Elderly Surgical Patients at High-risk with Indwelling Tube

目的探索根因分析法预防老年外科高危患者各类留置管道非计划性拔管的效果,以期提高患者住院期间的安全性。方法通过根因分析对老年外科高危患者各种留置管道非计划性拔管事件进行原因分析找出可能原因,遵照解放军总医院十项护理核心制度,加强其中值班交接班制度、分级护理巡视制度、护理安全评估及报告制度、使用约束患者管理制度等的执行力度,改善留置各类管道及约束具的固定方法,针对相关陪护人员进行更完善的训练,提高医护患间的沟通与合作等符合临床实际需求、个性化的整改措施,并与整改措施实施后的观察组进行对比分析。结果2009年7月至2011年7月各类留置管道非计划性拔管由5.0%下降到2011年7月至2013年7月的2.5%,差异有统计学意义(P<0.01)。结论根据老年外科高危患者的特点,严格落实各项制度的执行,加强各方沟通,设计及执行改善的行动计划,有效地降低了各类管道滑脱的发生率。

Objective To explore the effect of root cause analysis in the prevention of unplanned extubation in elderly surgical patients at high-risk with indwelling tube,in order to improve patient safety during hospitalization.Methods The root cause analysis method used to analysis data from elderly surgical patients at high risk of unplanned extubation various events to identify influencing factors.According to our hospital＇s ten core nursing care system,we enforced duty shift system,grading and inspection nursing system,safety assessment and reporting system,management of restraint usage system.We improved the fixing methods of pipelines constraints and training of the relevant accompanying personnels,and also pay more attention to communication and cooperation between healthcare personnels and patients,and individualized rectification measures.The effects of above prevention strategies were compared with the observation group at the end of this study.Results From July 2009 to July 2011,the incidence of unplanned indwelling pipelines extubation was 5.0%,and decreased to 2.5%from July 2011 to July 2013 after prevention strategies were taken（P〈0.01）.Conclusion Based on the characteristics of elderly surgical patients at high risk,strict implementation of the system execution,strengthen communication between the patients and healthcare personnels,improvement of the design and implementation of action,these prevention strategies effectively reduced the risks of unplanned indwelling pipelines extubation.