根本原因分析法在护生针刺伤事件分析中的应用

Application of root cause analysis method in the analysis of needle stick injuries in nursing students

目的:本文利用根本原因分析法(RCA)分析针刺伤事件1例。确定该事件为"实习同学针刺伤事件"。直接原因为护生操作不熟练,拔出头皮针时太用力,头皮针靠近肝素帽边缘。根本原因为培训不到位、防护意识差,带教老师强调不足,未告知拔出头皮针环节注意事项,未使用无针接头输液器。制定了改善方案。规范留置针操作培训,加强护生针刺伤的培训,提高防护意识,可有效预防护生针刺伤事件的发生。

The root cause analysis method(RCA)was used to analyze 1 case of needle stick injuries in this paper.Determine the incident as"internship classmate needle stick injury event".The direct reason is that the nursing students are not skilled in operation,pull out the scalp needle too hard,and the scalp needle is close to the edge of the heparin cap.The root cause is that the training is not in place,and the protection consciousness is poor,with a teacher shortage stressed,did not inform the pin pulled scalp links precautions,unused needle-free connector infusion.We developed a plan for improvement.To standardize the operation training of retaining needle,strengthen the training of nursing students' needle stick injury,raise the awareness of protection,which can effectively prevent the occurrence of needle stick injuries.