摘要
目的探讨运用根因分析法对导管滑脱事件进行分析制定对策,以降低住院患者非计划性拔管发生率,提高住院患者的安全性。方法对2014年6月—2015年12月发生的56例计划性拔管事件,运用柏拉图找出需要重点改善的项目,然后对重点项目进行根因分析,并进行干预。2016年1月—2017年6月对改进效果进行追踪。结果住院患者非计划性拔管发生率由2014年6月—2015年12月7.8%下降到2016年1月—2017年6月的2.3%,有效降低了非计划性拔管事件的发生。结论采用根因分析法能找到非计划性拔管发生的根本原因,并制定有效的对策。
Objective Explore using returning andrysis method to analyze catheter slippage event,develop countermeasures,to improve the safety of inpatients by reducing the incidence rate of unplanned extubation of inpatients.Methods The projects needing to be improved especially in 56 cases of unplanned extubation from June 2014 to December 2015 were found out by the Plato,then the root causes of key projects were analyzed and intervened in,and the improvement effect was traced from January 2016 to June 2017.Results The incidence rate of unplanned extubation of inpatients decreased from 7.8%from June 2014 to December 2015 to 2.3%from January 2016 to June 2017,thus effectively decreasing the occurrence of unplanned extubation events.Conclusion The root cause analysis can find out the root causes of unplanned extubation and make the effective strategies.
作者
罗娟
杨丽
唐明亚
LUO Juan;YANG Li;TANG Ming-ya(.Department of Nursing,Xiushan People’s Hospital,Chongqing,409900 China;Department of Orthopedics,Xiushan People’s Hospital,Chongqing,409900 China)
出处
《中国卫生产业》
2018年第2期167-169,共3页
China Health Industry
关键词
根因分析法
非计划性拔管
柏拉图
对策
Root cause analysis
Unplanned extubation
Pareto
Strategy
