1例CT增强药物渗漏的根本原因分析及护理干预

通过对1例CT增强药物渗漏进行根本原因分析，依次应用事件描述表、流程图、鱼骨图、流程解构图、改善对策执行管理表等工具，增加分析过程的逻辑性和条理性，呈现“CT增强药物渗漏”事件的根本原因，帮助护理管理者和分析人员理清思路，提高分析能力，更好地辨识事件发生的原因，提出改善对策与防范措施。

Through the 1 CT enhancement drug leakage for root cause analysis, ordinal application event description table, flow chart, fishbone diagram, process, deconstruction diagrams, improving countermeasure implementation management table tools, such as increasing the analysis process of logical and orderly, rendering the root cause of the ＂CT enhancement drugs leakage incident, clear up the thoughts to help nursing managers and analysts. Improve the ability of analysis, to better identify the cause of the incident, the improvement countermeasures and preventive measures are put forward.