基于根本原因分析法的三级审核在降低住院患者跌倒发生率中的应用

Application of three-level audit based on root cause analysis in reducing the incidence of falls in hospitalized patients

目的探讨根本原因分析法的三级审核在降低外科住院患者跌倒发生率中的应用效果。方法运用根本原因分析法对外科住院患者发生的跌倒不良事件进行回顾性分析,找到发生不良事件的原因,制定相应的预防措施,比较预防措施实施前后跌倒事件发生情况。结果应用预防措施后跌倒事件发生率低于干预前,差异有统计学意义(P<0.05)。结论对外科住院患者应用根本原因分析法的三级审核,找到预防跌倒发生的护理措施,可明显减少跌倒发生,提高患者安全性和医院护理质量。

Objective To explore the application of three-level audit based on root cause analysis in reducing the incidence of falls in hospitalized patients.Methods To retrospectively analyze the adverse events of falls surgical inpatients by applying the root cause analysis method,in order to find the cause of the adverse events,formulate corresponding preventive measures,and compare the occurrence of falls before and after the preventive measures were implemented.Results The incidence of falls after applying preventive measures was lower than that before intervention,and the difference was statistically significant(P<0.05).Conclusion Applying the three-level audit based on root cause analysis to surgical inpatients and finding nursing measures to prevent falls can significantly reduce the occurrence of falls and improve patient's safety and hospital nursing quality.