手术电刀爆燃事件根本原因分析与思考-《中国卫生质量管理》

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摘要:: 目的探寻手术室高频电刀爆燃事件的根本原因，并采取措施降低安全风险。方法采用RCA分析的方法，以差异分析为手段，回顾分析事件发生根本原因。结果事件发生与人员因素、制度规范因素、设备因素有关，在采取针对改进措施后，未发生爆燃事件。结论通过对事件开展有效分析，提出改进措施后进行持续改进，能够筑立风险防范屏障，避免电刀爆燃事件发生的风险。

Abstract:: ObjectiveTo explore the root causes of high-frequency electric knife deflagration in operating room and find effective measures to reduce the safety risk.MethodsUsing the method of difference analysis with root cause analysis to retrospectively analyze the root causes of the event.ResultsThe occurrence of the incident was related to personnel factor, institutional factor, and equipment factor. The deflagration event had not occurred after taking the improvement measures.Conclusion Through the effective analysis of the event and the continuous improvement after the improvement measures being put forward, the risk prevention barrier can be built and the risk of electric knife deflagration event can be reduced.