根本原因分析法在手术室患者坠床管理中的应用

Application of Root Cause Analysis in the management of patients' falls in the operating room

目的:评价根本原因分析法(RCA)在手术室患者坠床管理中的应用效果,为临床手术患者安全管理提供参考。方法:建立RCA小组,通过访谈和现场考察收集事件相关资料,通过时间序列表罗列手术室患者坠床事件过程,识别近端原因,借助鱼骨图进行分析以确定根本原因,制定改善行动计划表,组织实施并评估改善效果。结果:实施一系列改善行动后,约束带使用规范率、手术安全管理培训完成率、防坠床/跌倒指示牌正确放置指定位置比例均达到100%。结论:应用RCA分析手术室患者坠床这一不良事件,有助于促进医院系统安全,增强医护人员的安全意识,优化医疗服务,确保患者的医疗质量和安全水平得到有效提升。

Objective:To investigate the effect of Root Cause Analysis(RCA) in the management of patients falling from bed in the operating room.Methods:An RCA team was established to collect relevant information of patients' falls through interviewing and site investigation to chronologically display the whole process of the falling events in operating room,identify the recent causes to determine the root cause using fishbone diagram analysis,so that a better action plan could be implemented to evaluate the effectiveness.Results:After the implementation of the improvement action,the rate of properly using restraint belts,the rate of finishing surgical safety training,and the ratio of falling signs all reached 100%.Conclusion:The application of RCA to analyze patient' falling from bed in the operating room is helpful to enhance the safety system of the hospital,strengthen medical staff's safety awareness to improve medical quality and ensure patient safety.