根本原因分析法对脑外伤术后患者压疮发生风险的影响

Effect of Root Cause Analysis on the Risk of Pressure Ulcer in Patients with Traumatic Brain Injury

目的探讨根本原因分析法(root cause analysis,RCA)在脑外伤术后压疮预防护理中的应用效果。方法 2016年2月-2019年2月对该院脑外科术后压疮预防护理措施实施RCA,查找问题及隐患,分析原因,提出解决措施,修改护理流程及措施,对护理人员培训,RCA后按改进护理措施进行护理,采用Braden量表及Shea分级量表评价RCA实施前(对照组)及实施RCA后(研究组)压疮发生风险变化。结果研究组及对照组术前Braden评分差异无统计学意义(P>0.05),手术后第3天及第7天两组患者Braden评分均较术前降低(P<0.05),研究组术后第3天及第7天Braden评分均高于对照组(P<0.05)。研究组术后压疮NPUAP分期低于对照组(P<0.05)。结论根本原因分析法能够降低脑外伤术后患者压疮发生风险,提高皮肤护理质量,改善护理效果。

Objective To explore the application effect of Root Cause Analysis (RCA) in the prevention and treatment of pressure sore after traumatic brain injury. Methods From February 2016 to February 2019, we implemented RCA on preventive nursing measures for pressure ulcers after brain surgery in the hospital, to find problems and hidden dangers, analyze the causes, propose solutions, modify the nursing procedures and measures, and train the nursing staff after RCA. According to the improved nursing measures, the Braden scale and Shea grading scale were used to evaluate the risk changes of pressure ulcers before RCA(control group) and after RCA (study group). Results There was no statistically significant difference in the preoperative Braden score between the study group and the control group (P>0.05). The Braden scores of the two groups were lower than those before the operation on the 3rd and 7th day after surgery (P<0.05). The Braden scores on the 3rd and 7th day were higher than those in the control group (P<0.05). The NPUAP stage of postoperative pressure ulcer in the study group was lower than in the control group (P<0.05). Conclusion Root cause analysis can reduce the risk of pressure ulcers in patients with traumatic brain injury, improve the quality of skin care and improve the nursing effect.