根本原因分析行动在降低ICU患者非计划拔管中的应用

The effects of root cause analysis and actions on reducing unplanned extubation of patients in ICU

目的探讨应用根本原因分析行动(root cause analysis and actions,RCA^2)降低ICU患者非计划拔管的方法和效果。方法应用RCA^2对ICU患者非计划拔管的问题进行干预,主要包括:组建团队,收集资料;查找直接原因;确认根本原因;拟定改善计划;落实改善计划。比较干预前后ICU患者的非计划拔管率。结果 ICU患者的非计划拔管率干预前为2.56%(20/782),干预后为0.41%(3/736),差异有统计学意义(χ~2=11.745,P<0.001)。结论RCA^2的系统干预有效降低ICU患者非计划拔管发生率,规范化的科学管理和多部门协作有助于保障患者安全。

Objective To evaluate the effects of root cause analysis and actions （RCA^2） on reducing unplanned extubation of patients in ICU. Methods Interventions were implemented by using RCA^2 to deal with the unplanned extubation of patients in ICU. Details were as follows ：building up the team and collecting data;looking for the direct reasons,identifying the root causes,making planning,and implementing the interventions. The unplanned extubation rate of ICU patients before and after the intervention was compared. Results The incidence of unplanned extubation of patients before the intervention was 2.56% （20/782）,while it was 0.41%（3/736） after the intervention. The differences were statistically significant （χ^=11.745,P〈0.001）. Conclusion RCA2 can effectively reduce the incidence of unplanned extubation in ICU patients. Standardized scientific management and collaboration among different departments can contribute to patient safety.