应用RCA^2分析患者担架坠落根因

Application of RCA^2 in Improvement of Patient’s Stretcher Transport Fall Event

对1例患者担架转运坠落事件展开根本原因分析,认为沟通不到位、无约束带装置、无转运约束指南为事件发生根本原因.对此,重申医护沟通重要性,在担架上加装约束带,并制定患者担架转运约束指南.通过改进,类似不良事件未再次发生,效果良好.

The root cause analysis was carried out on a patient's stretcher transport fall event. It was considered thatthe root causes of the incident included the inadequatecommunication, the unconstrained device, and the no-transport constraint guide. In this regard, the importance of health care communication was reaffirmed, a restraint band on the stretcher was installed, and guidelines for patient stretcher transport restrictions was developed. Through the improvement, similar adverse events did not happen again, and the effect was good.