摘要
目的：为医院管理者应用RCA品质改善手法的运用提供借鉴。方法根据现实的案例（异丙嗪特殊给药途径用药途径错误导致患者意识改变）应用RCA手法进行对案例分析，提出改进建议进行品质改善。结果2012年6月~2014年1月期间医院未发生因为特殊给药途径的药物用药途径错误的现象。结论运用RCA手法能找出事件的系统原因，剖析原因采取相应的实际行动来加以改进，并分享案例改进方法，杜绝此类事件的再发生。
Objective To offer reference that the hospital governors use RCA quality improvement method. Methods Carries on the case analysis according to the case using RCA methods of reality, such as promethazine special to the wrong medicine drug approaches pathways leading to patient consciousness change, put forward the improvement pro-posal for quality improvement. Results During the period from June 2012 to January 2014 , the hospital did not happen because the drugs special route of administration way wrong phenomenon. Conclusion Application of RCA techniques can help us find the system reasons for the incident, and then analyze the reasons, to take practical action to improve the corresponding. And share the case method, put an end to these events.
出处
《中国现代医生》
2014年第24期119-122,共4页
China Modern Doctor
基金
浙江省康恩贝医院管理软科学研究项目(2012ZHA-KEB325)
关键词
品质改善
给药错误
异丙嗪
Quality improvement Medication errors Promethazine
