新冠病毒疫情相关不良事件的根因分析及管理实践

Root cause analysis and management practice in adverse events related to COVID-19 in epidemic

目的探讨根因分析法在处置新型冠状病毒肺炎(简称新冠肺炎)疫情相关不良事件中的应用及持续改进的管理成效。方法对新冠肺炎疫情关联的不良事件个案展开根因分析,探寻根本原因,制定并落实改进措施,全程督导其效果。结果方案实施后,疫情期间工作人员零感染,未出现院内感染病例;提升了不良事件的处置水平,病区管理评价指标改善显著。结论不良事件的根因分析及持续改进能够促进制度完善、保证医疗安全并成为院内感控管理的有益补充。

Objective To explore the application of root cause analysis in dealing with adverse events related to novel coronavirus 2019(COVID-19)during the epidemic and the management effect of continuous improvement.Methods The root cause analysis was conducted on the adverse events associated with COVID-19,and improvement measures were formulated and implemented.The effects were supervised throughout the whole process.Results After the implementation of the scheme,there was no infection among staff and no case of nosocomial infection during the epidemic.The management of adverse events has been improved,and the evaluation index of ward management has improved significantly.Conclusion Root cause analysis and continuous improvement of adverse events can promote system improvement,ensure medical safety,and become a useful supplement to nosocomial infection control.