根本原因分析法在危重症患者非计划性拔管中的应用研究

Application research on root cause analysis method in non-planned-extubation of patients with critical illness

目的探讨根本原因分析法在危重症患者非计划拔管中的应用价值。方法针对2013年1—12月期间我院危重症患者非计划拔管事件13起,采用根本原因分析法进行分析,找出发生非计划拔管的根本原因,并制定针对性的防范措施;记录2014年1—12月期间危重症患者的非计划拔管数,并对实施根本原因分析法前后危重症患者非计划拔管率进行比较。结果 2013年1—12月实施根本原因分析法前的非计划拔管率为3.69%,2014年1—12月实施根本原因分析法的非计划拔管率为1.22%,实施根本原因分析法后,非计划拔管率有了明显下降,实施前后差异具有统计学意义(P<0.05)。结论对危重症患者实施根本原因分析法,可以有效降低患者的非计划拔管率,具有临床应用价值。

Objective To investigate clinical value oi root cause analysis method m hon-planned- extubation of patients with critical illness. Methods In view of the 13 cases of the non-planned-extubation in our hospital during the year of 2013, the basic reason analysis method was used to find out the root cause and the preventive measures. The number of unplanned extubation in patients with critical illness during the period of 2014 was recorded, and the non-planned-extubation rate was compared with the implementation of the root cause analysis method. Results The non-planned-extubation rate was 3.69% during 2013 by implementing root cause analysis, the implementation of the basic reason analysis method in 2014 for non-planned- extubation rate was 1. 22%. After the implementation of root cause analysis method, the rate of unplanned extubation was significantly decreased, and the difference was statistically significant （ P 〈 0. 05 ）. Conclusions The implementation of the basic reason analysis method, can effectively reduce the patient ~s unplanned extubation rate, with clinical application value.