基于根因分析法的3例手术室深静脉非计划性拔管原因分析及护理对策

Cause and Nursing Measure of Three Cases of Unplanned Extubations of Deep Vein in Operating Room: a Root Cause Analysis

目的分析手术室深静脉置管患者非计划性拔管的原因,制定防范措施,优化规范护理操作流程,防范非计划拔管的发生。方法采用根因分析法(RCA)对2017年6月至2018年8月(改进前)四川省肿瘤医院手术室发生的深静脉置管患者非计划性拔管原因进行回顾性总结,分析深静脉置管非计划性拔管的原因,提升执行力,改进固定方法,制定操作规范,细化手术患者转运交接流程,制定防范对策。2018年9月至2019年7月(改进后),应用改进后的护理操作流程观察结果,再优化操作流程。结果改进前手术室共发生3例非计划性拔管事件;按规范实施改进后,未发生非计划性拔管事件,护士转运患者的规范性得到提高。改进前,转运规范性操作的人数占总人数70.0%;改进后,转运规范性操作的人数占总人数92.5%,改进前后得分差异有统计学意义(P<0.01)。雷达图显示,根因分析法提示小组组员的自我能力得到提升。结论采用RCA找出非计划性拔管的根本原因,以及根据原因制定快速有效的方法解决和改进操作流程,特别是改进深静脉固定方法,可以有效降低非计划性拔管的发生。

Objective To analyze the causes of unplanned extubation of patients with deep vein catheterization in the operating room, so as to formulate preventive measures, optimize and standardize nursing operation procedures, and prevent the occurrence of unplanned extubation. Methods The causes of unplanned extubation of patients with deep vein catheterization in the operating room of Sichuan Cancer Hospital from June 2017 to August 2018 were summarized and analyzed retrospectively by root cause analysis(RCA). Accordingly, measures were taken to improve executive ability, better the fixation method, formulate operation specification, refine transfer and handover process of surgical patients, and develop the prevention measures. From September 2018 to July 2019, the improved nursing operation process was applied, the results were observed, and then the operation process was re-optimized. Results Before the improvement of the operation process, 3 cases of unplanned extubation occurred in the operating room, while after the improvement was implemented according to the standard, no unplanned extubation occurred. The standardization of nurses’ transport patients was improved. Before an after the improvement, the number of nurses performing standard transport operation accounted for 70.0% and 92.5% of the total number of nurses investigated respectively, and the percentage difference before and after the improvement was statistically significant(P<0.01). The radar map showed that RCA helped improve the group members’ abilities. Conclusion The occurrence of unplanned extubation of deep vein can be effectively reduced by finding out its root cause by RCA, and developing quick and effective methods to solve problems and improve the operation process, especially the fixation method of deep vein.