不良结局护理中断事件根本原因分析与改进

Adverse outcomes associated with interruptions in nursing practice:root cause analysis and countermeasures

目的探讨根本原因分析法在不良结局护理中断事件管理中的应用效果。方法应用根本原因分析法对13例不良结局护理中断事件进行分析,找出根本原因,制定改进措施,实施专项管理,1年后评价效果。结果改进措施实施后护理不良事件及不良结局护理中断事件发生率较改进措施实施前显著下降(均P<0.01)。结论根本原因分析法用于护理安全管理可有效降低不良事件及不良结局护理中断事件发生率,保障患者安全。

Objective To investigate the effect of root cause analysis applied in management of adverse events induced by interruptions in nursing practice. Methods We used root cause analysis to identify the root causes of 13 adverse events associated with interrup tions in nursing care, then developed and implemented countermeasures. The effect was evaluated 1 year after the intervention. Resalts The incidence rates of adverse events and interruption-induced adverse events were significantly decreased after the intervention （P〈0.01 for both）. Conclusion Application of root cause analysis in patient safety management can effectively reduce adverse events and interruption-induced adverse events, thus to ensure patient safety.