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[1]李俊杰张琳娟梅娜罗嘉婷.基于RCA的手术纱布清点不良事件改进效果研究[J].中国卫生质量管理,2024,31(07):67-71.[doi:10.13912/j.cnki.chqm.2024.31.7.15]
　LI Junjie,ZHANG Linjuan,MEI Na.The Improvement Effect of Surgical Gauze Counting Adverse Events Based on Root Cause Analysis[J].Chinese Health Quality Management,2024,31(07):67-71.[doi:10.13912/j.cnki.chqm.2024.31.7.15]

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基于RCA的手术纱布清点不良事件改进效果研究

《中国卫生质量管理》[ISSN:1006-7515/CN:CN 61-1283/R] 卷: 第31卷期数: 2024年07期页码: 67-71 栏目: 患者安全出版日期: 2024-07-15

Title:: The Improvement Effect of Surgical Gauze Counting Adverse Events Based on Root Cause Analysis

作者:: 李俊杰张琳娟梅娜罗嘉婷; 西安交通大学第一附属医院

Author(s):: LI Junjie; ZHANG Linjuan; MEI Na; The First Affiliated Hospital of Xi’an Jiaotong University

关键词:: 根本原因分析法; 手术室; 物品清点; 不良事件; 患者安全

Keywords:: Root Cause Analysis; Operating Room; Inventory of Goods; Adverse Events; Patient Safety

分类号:: R197.32

DOI:: 10.13912/j.cnki.chqm.2024.31.7.15

文献标志码:: B

摘要:: 目的探讨根本原因分析法（RCA）在手术纱布清点不良事件中的应用效果。方法组建RCA小组，回溯事件经过并使用时间序列表整理资料，找出近端原因后采用改良原因树图分析根本原因，通过屏障分析、拟订行动计划，最终组织实施并长期监测持续改进效果。结果改进后术后纱布入袋执行率、自然腔道手术物品清点率、台上小纱布定点放置执行率、保洁人员垃圾袋不叠套执行率明显上升（P＜0.05），为医务部提供了接台时间检查基线（5 min），并研发了一种可以识别纱布一致性的清点设备。结论应用RCA进行手术纱布清点不良事件分析，能够更加清晰地识别手术室纱布清点流程中的系统缺陷并针对性改进，从而有效规避护理风险，保障患者安全。

Abstract:: ObjectiveTo explore the application effect of root cause analysis (RCA) in counting adverse events of surgical gauze.MethodsThe RCA team was established to trace the event process, and use a time series table to organize data. After identifying the proximal cause, an improved causal tree was used to analyze the root causes. Through barrier analysis, the formulation and ultimately implementation of action plans, long-term monitoring of continuous improvement effects was carried out.ResultsAfter the improvement, the implementation rate of gauze into the bag, the inventory rate of natural cavity surgical items, the fixed-point placement rate of small gauze on the stage, and the non-stacking implementation rate of cleaning garbage bags increased significantly (P<0.05). The baseline of pick-up time for the medical department (5 minutes) was provided, and a kind of counting equipment which can identify the consistency of gauze was developed.Conclusion The application of RCA in the analysis of adverse events of surgical gauze counting can more clearly identify the system defects in the gauze counting process in the operating room and make targeted improvements, so as to effectively avoid nursing risks and ensure patient safety.

参考文献/References:

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更新日期/Last Update: 2024-07-15