摘要
连续性血液净化是肾脏替代治疗方法,是缓慢且长时间持续的血液过滤方式。自体动静脉内瘘(AVF)是连续性血液净化血管通路之一,在AVF使用过程中常见并发皮下血肿,动静脉内瘘血肿可引发内瘘血管内膜增生狭窄、闭塞、血流量不足等,影响患者的治疗和预后。本文回顾分析了1例应用根本原因分析法对连续性血液净化患者内瘘血肿的干预情况,根据鱼骨图和5Why法剖析根本原因并制订、实施改进对策,使科室加强了对血液净化血管通路安全环节的质量监控,旨在杜绝此类不良事件的再次发生,提高患者满意度。
Continuous blood purification is a method of renal replacement therapy,which is a slow and long lasting blood filtration method.Autologous arteriovenous fistula(AVF)is one of the continuous blood purification vascular access.Subcutaneous hematoma is common during the use of AVF,and arterio-venous fistula hematoma can cause hyperplasia,stenosis,occlusion,and insufficient blood flow of the inner vascular membrane of fistula,affecting the treatment and prognosis of patients.This paper reviewed and analyzed the intervention situation of one case of internal fistula hematoma in continuous blood purification patients with the application of root cause analysis,analyzed the root cause according to fishbone diagram and 5Why method,and formulated and implemented improvement countermeasures,which made the department strengthen the quality control of the safety link of blood purification vascular access,in order to prevent the recurrence of such adverse events and improve patient satisfaction.
作者
蒋丽琼
罗畅
吴传芳
戴凡
文艳红
陈琼芳
JIANG Liqiong;LUO Chang;WU Chuanfang;DAI Fan;WEN Yanhong;CHEN Qiongfang(Blood Purification Center,Changsha Central Hospital,Hu'nan Province,Changsha410000,China;Department of Nursing,Changsha Central Hospital,Hu'nan Province,Changsha410000,China;College of Nursing,Hu'nan University of Chinese Medicine,Hu'nan Province,Changsha410000,China;Department of Nephrology,Changsha Central Hospital,Hu'nan Province,Changsha410000,China)
出处
《中国当代医药》
CAS
2023年第3期185-188,共4页
China Modern Medicine
基金
湖南省自然科学基金科卫联合项目(2019JJ80052)
湖南省卫生健康委科研立项课题(20201976)。
关键词
根因分析
动静脉内瘘
血肿
安全性
Root cause analysis
Arteriovenous fistula
Hematoma
Safety
