根本原因分析法在日间手术患者身份识别流程改进中的应用

Root Cause Analysis in the improvement of identification process of day surgery patients

目的:调查根本原因分析法(RCA)在日间手术患者身份识别流程改进中的应用效果。方法:成立RCA小组,搜集事件相关资料,通过时间序列表叙述日间手术患者身份识别错误事件经过,找出近端原因,应用问题树、鱼骨图分析来确定根本原因,进行屏障分析,制定改善行动计划表,组织实施并进行效果评价。结果:改善行动实施后,预手术患者身份核查规范率明显上升(P<0.05);手术当日临时调台率下降(P<0.05);预住院期间门诊检查费用医保支付比例、相关人员日间手术运行流程培训完成率、电子版手术通知单使用率、指示牌放置指定位置比例、患者身份识别准确率均为100%。结论:应用RCA分析日间手术患者身份识别错误这一手术室警讯事件,有助于更好地识别手术室工作流程中的系统缺陷,确定根本原因,制定改善行动方案,提升医疗质量,确保患者安全。

Objective:To analyze the effects of Root Cause Analysis(RCA)applied in improving the identification process of day surgery patients.Methods:Established an RCA group to collect event-related information,restored the event process through the time sequence list,found the proximal cause,analyzed and determined the root cause by the problem tree and fishbone diagram,performed barrier assays,formulated and implemented improvement action schedule,then evaluated the effects.Results:After the implement of improvement action,the incidence of irregular identity verification for the preoperative patients decreased significantly(P<0.05).The temporary adjustment rate of operating table also significantly decreased(P<0.05).The ratio of paying outpatient examination fee during pre-hospitalization with health insurance,completion rate of relevant personnel day surgery operation process training,usage rate of electronic surgery notice,correct rate of sign placement and accuracy rate of patient identification all achieved 100%.Conclusion:Applicating RCA to analyze the surgical patient identification error can better help identify system defects in the operating room workflow,identify root cause,formulate action improvement plan,improve medical quality,and ensure patient safety.