摘要
针对1例血小板输错事件,成立RCA团队,完成事件描述表,应用鱼骨图寻找近端原因,采用五问法剖析根本原因,制定针对性改进对策并落实,为临床安全用血提供保障。
As for one case of platelet transfusion error, the team on root cause analysis （ RCA ） was established to complete events description table, fishbone diagram was used to find proximal reasons for the event. The five questions method was used to analyze root causes, and targeted improvement measures were developed and implemented, which provides effective protection on the safety of clinical blood use.
出处
《中国卫生质量管理》
2016年第2期13-15,共3页
Chinese Health Quality Management
关键词
根本原因分析
临床用血
闭环管理
Root Cause Analysis
Clinical Blood Use
Closed - Loop Management
