根因分析法在降低中高危导管非计划性拔管发生率中的应用

Application of root cause analysis in reducing the incidence of unplanned extubation of medium-and high-risk catheters

目的探讨根因分析法对三级医院近三年不良事件中高危导管非计划性拔管发生率的影响,并建立非计划性拔管的风险管理体系,提高患者的医疗安全。方法将2020年1月-2020年12月江苏盛泽医院留置中高危导管患者的UEX发生率设为对照组,将2021年1月-2022年11月江苏盛泽医院留置中高危导管患者的UEX发生率设为实验组,以根因分析法查找发生中高危导管非计划性拔管的因素,据此制定出相应的整改措施,包括通过信息系统提醒功能来加强医护人员对患者的意识评估及患者的镇静、镇痛管理;规范患者约束,弱化低危导管的UEX事件来降低患者约束率;通过工作坊培训方式来规范导管固定方式;小视频方式加强患者及家属导管宣教;设置床边提醒装置及中高危导管警示标志,最终建立系统的风险管理体系。对比两组患者中高危导管非计划性拔管的发生率。结果通过应用根因分析法,观察组住院患者非计划性拔管发生率(0.247%)低于对照组患者发生率(0.683%),差异有统计学意义(P<0.05)。结论根因分析法在综合医院住院患者非计划性拔管风险管理体系中的建立和应用,可以有效降低中高危导管非计划性拔管率,在降低护理风险的同时保障患者的安全,值得临床应用和推广。

Objective To investigate the effect of root cause analysis on the unplanned withdrawal of high-risk catheters during adverse events in tertiary hospitals in recent three years,the risk management system of unplanned extubation was established to improve the medical safety of patients.Methods UEX of patients with medium-high risk catheters were indwelled in Shengze Hospital of Jiangsu Province from January 2020 to December 2020 The incidence rate was set as the control group,and the medium-high risk guide was indwelled in Jiangsu Shengze Hospital from January 2021 to November 2022 The incidence of UEX in patients with tube management was set as the experimental group.Root cause analysis was used to find the factors that caused unplanned extubation of high-risk catheters.and corresponding corrective measures were formulated accordingly,including strengthening the awareness assessment of medical staff on patients and sedation and analgesia management of patients through the reminding function of information system.Regulate patient restraint,weaken the UEX event of low-risk catheter to reduce the patient restraint rate;standardize catheter fixation through workshop training;small video method to strengthen the catheter education of patients and their families;set up bedside warning devices and warning signs for dangerous catheters in high schools,and finally establish a systematic risk management system.The incidence of unplanned extubation of high-risk catheter was compared between the two groups.Results Through the application of root cause analysis,the incidence of unplanned extubation in the observation group(0.247%o)was lower than that in the control group(0.683%o),and the difference was statistically significant(P<0.05).Conclusion The establishment and application of root cause analysis in the risk management system of non-planned extubation of inpatients in general hospitals can effectively reduce the rate of unplanned extubation of high-risk catheters,reduce nursing risks and guarantee the safety of patients,and is worthy of clinical application and promotion.