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[1]何芝易冯志仙陈翔方小妹.根本原因分析法在一例半开放式精神科住院患者割腕自杀事件中的应用[J].中国卫生质量管理,2025,32(12):70-75.[doi:10.13912/j.cnki.chqm.2025.32.12.14]
　HE Zhiyi,FENG Zhixian,CHEN Xiang.Application of Root Cause Analysis in a Case of Wrist-Cutting Suicide by a Semi-Open Psychiatric Inpatient[J].Chinese Health Quality Management,2025,32(12):70-75.[doi:10.13912/j.cnki.chqm.2025.32.12.14]

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根本原因分析法在一例半开放式精神科住院患者割腕自杀事件中的应用

《中国卫生质量管理》[ISSN:1006-7515/CN:CN 61-1283/R] 卷: 32 期数: 2025年12期页码: 70-75 栏目: 质量管理方法与工具出版日期: 2025-12-15

Title:: Application of Root Cause Analysis in a Case of Wrist-Cutting Suicide by a Semi-Open Psychiatric Inpatient

作者:: 何芝易冯志仙陈翔方小妹; 树兰（杭州）医院

Author(s):: HE Zhiyi; FENG Zhixian; CHEN Xiang; Shulan(Hangzhou) Hospital

关键词:: 根本原因分析法; 半开放式精神科; 自杀事件; 患者安全

Keywords:: Root Cause Analysis; Semi-Open Psychiatry; Suicide Incident; Patient Safety

分类号:: R197.323

DOI:: 10.13912/j.cnki.chqm.2025.32.12.14

文献标志码:: B

摘要:: 目的探讨根本原因分析法（RCA）在一例半开放式精神科住院患者割腕自杀事件中的应用效果，为精神科患者安全管理提供参考。方法建立RCA小组，通过深度访谈、现场考查等方式系统收集事件资料，采用时间序列表详细梳理事件发生经过，运用差异分析、鱼骨图、故障树等工具系统识别事件发生的根本原因，制订并实施针对性改善行动计划。结果患者及家属对精神科安全管理宣教内容知晓率提升至95%以上；风险评估落实率、入院知情同意告知落实率、危险物品双人排查落实率等均达100%；半开放式精神科病房护士岗位胜任力考核通过率和医生疾病诊疗规范培训考核合格率均提升至100%。结论将RCA应用于半开放式精神科住院患者不良事件分析中，能够准确把握事件发生的根本原因，有效促进医院安全系统优化，强化了医护人员安全意识，确保精神科患者的医疗质量与安全。

Abstract:: ObjectiveTo explore the application effects of Root Cause Analysis (RCA) in a case of wrist-cutting suicide by a semi-open psychiatric inpatient, providing references for safety management in psychiatric patients.MethodsAn RCA team was established to systematically collect event data through in-depth interviews and on-site investigations. The sequence of events was detailed using a timeline. Tools such as difference analysis, fishbone diagrams, and fault tree analysis were employed to systematically identify the root causes of the event. A targeted improvement action plan was then developed and implemented.ResultsThe awareness rate of psychiatric safety management education content among patients and their families increased to over 95%. The implementation rates of risk assessment, informed consent disclosure upon admission, and dual-person inspections for hazardous items all reached 100%. The pass rates for competency assessments among nurses in semi-open psychiatric wards and for training evaluations on disease diagnosis and treatment standards among doctors both increased to 100%.Conclusion Applying RCA to the analysis of adverse events in semi-open psychiatric inpatients enables accurate identification of the root causes of incidents. This approach effectively promotes the optimization of hospital safety systems, strengthens healthcare personnel’s safety awareness, and provides support for ensuring the medical quality and safety of psychiatric patients.

参考文献/References:

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更新日期/Last Update: 2025-12-15