根因分析法在患者高危药物外渗预防中的应用

Application of Root Cause Analysis in Preventing Extravasation of High-risk Drugs in Patients

目的探讨根因分析法在患者高危药物外渗预防的应用效果。方法通过对本院2016年发生的20例高危药物外渗病例进行分析,找出近端原因,确定根本原因,制定实施改进措施;统计本院2017年高危药物外渗发生率,并与2016年进行比较。结果经过一系列的整改措施后,2017年本院高危药物外渗发生率为0.066%(9/13671),明显低于2016年的0.165%(20/12089),差异有统计学意义(P<0.05)。结论根因分析法是一个科学有效的护理质量管理工具,能够降低高危药物外渗发生率,保证高危药物输注的护理质量和安全,值得推广。

Objective To explore the effect of root cause analysis in reducing the extravasation of high-risk drugs in patients.Methods Through the analysis of 20 high-risk drug extravasation cases in our hospital in 2016,the proximal causes were found out, the root cause were determined, and implement improvement measures was formulated and implemented.Statistics of the incidence of high-risk drug leakage in our hospital in 2017 were compared with 2016.Results After a series of rectification measures, the incidence of high-risk drug leakage in our hospital in 2017 was 0.066%(9/13671),which was significantly lower than 0.165%(20/12089) in 2016,and the difference was statistically significant(P<0.05).Conclusion Root cause analysis is a scientific and effective nursing quality management tool, which can reduce the incidence of high-risk drug leakage and improve the quality and safety of nursing care of high-risk drugs.It is worthy of promotion.