基于RCA的非计划性拔管影响因素分析及系统干预

Influencing Factors Analysis on Unplanned Extubation Based on Root Cause Analysis and Relevant Intervention

目的寻找造成非计划性拔管的根本原因,并依靠系统干预采取有效手段达到改善的目的。方法基于信息系统、采用根本原因分析法对2012年-2013年193例非计划性拔管行为特征进行回顾性分析,于2014年-2015年提出并实施基于多学科的、系统性的改善策略,对比实施前后非计划性拔管发生情况。结果实施前后全院非计划性拔管发生率由2.24‰下降至0.85‰,X^2=57.235,P<0.05,有统计学差异。因团队合作缺陷,如拔管时机、镇静等造成的非计划性拔管下降,重新置管率由56.95%上升至71.60%,X^2=5.134,P<0.05,有统计学差异。结论基于RCA的原因挖掘和系统干预手段有效解决了某院非计划性拔管发生率居高不下的患者安全问题,并推动了以"患者为中心"的团队合作和基于证据的作业流程制定方法。

Objective To find the primary causes of unplanned extubation, and achieve the purpose of improving by effective measures depending on system intervention.Methods To conduct a retrospective analysis on the characteristics of 193 cases of unplanned extubation from 2012 to 2013 with the application of primary causes analysis method, analyze the multidisciplinary and systematic improvement strategies proposed and implemented from 2014 to 2015, then compare with the situations before and after the implementation of unplanned extubation. Results The unplanned extubation incidence rate decreased from 2.24‰ to 1.79‰ after the application in the whole hospital, c2=57.235,P〈0.05,and had statistical significance. The decline of unplanned extubation because of the team cooperation defects, such as the timing of extubation, sedation led the re-catheterization rate was increased from 56.95% to 71.60%, c2=10.589, P〈0.05, and had statistical significance. Conclusions The mining for reasons and system interventions based on RCA effectively solved the security problems of high incidence of unplanned extubation in a hospital, and promoted the＂patient-centered＂teamwork and work flow strategy making method based on evidence.