眼科手术眼别错误踪近差错事件的RCA分析

RCA Analysis of Near Error Events of Eye Error Tracking in Ophthalmic Surgery

目的:运用质量管理工具进行眼科手术眼别错误踪近差错事件进行分析,找出非人为因素对该事件的影响并对其进行改善。方法:2018年郑州市某三级甲等医院眼科手术部发生的医疗/护理相关安全事件数据,运用根本原因分析(root cause analysis,RCA)对1例典型案例进行近端原因分析及通过对眼科手术全核查现状调查进行根本原因的分析,并采取措施提供解决方案,并于实施半年后评估整改成效。结果:运用RCA特定步骤组建小组完成根本原因分析后采取相关干预措施,手术安全核查执行率由65%提高至96%,至2019年12月底未发生相关类似踪近差错事件。结论:运用科学质量管理工具RCA,可有效减少眼别错误类似事件的发生。

Objective:To find out the influence of non-human factors on the near error event of eye error trace in ophthalmic surgery by using quality management tools.Methods:Retrospective analysis was made on the data of medical/nursing related safety events in the ophthalmic operation department of a three A hospital in Zhengzhou in 2018.Root cause analysis(RCA)was used to analyze the proximal cause of a typical case.The root cause analysis was conducted by investigating the current situation of ophthalmic surgery safety verification,then take measures to provide solutions,and evaluate the effect of rectification after half a year of implementation.Results:There were 3 similar near miss events in total.The RCA specific steps were used to form a team to complete the root cause analysis,relevant interventions were taken.The implementation rate of operation safety verification increased from 65%to 96%,and no similar near miss events occurred by the end of December 2019.Conclusion:Scientific quality management tool RCA can effectively reduce the occurrence of similar ocular errors.