[1]谢树英.1例行MRI检查导致胰岛素泵磁化不良事件的根因分析[J].中国卫生质量管理,2017,24(05):053-55.[doi:10.13912/j.cnki.chqm.2017.24.5.18]
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1例行MRI检查导致胰岛素泵磁化不良事件的根因分析
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《中国卫生质量管理》[ISSN:1006-7515/CN:CN 61-1283/R]

卷:
第24卷
期数:
2017年05期
页码:
053-55
栏目:
质量案例
出版日期:
2017-09-28

文章信息/Info

作者:
谢树英
赣州市人民医院
关键词:
MRI检查胰岛素泵磁化不良事件
Keywords:
MRI Examination Insulin PumpMagnetization Adverse Events
DOI:
10.13912/j.cnki.chqm.2017.24.5.18
摘要:
对内分泌科1例患者行MRI检查导致胰岛素泵磁化的不良事件进行分析,根据RCA步骤,从事件发生时间序列表、鱼骨图、防控对策实施、追踪评价等方面分析该事件发生的根本原因,优化工作流程,制定相应对策,基本杜绝了此类不良事件的发生,增强了员工的安全意识,提高了患者的满意度。
Abstract:
One case of adverse event of insulin pump magnetization by MRI examination in the Department of Endocrinology was analyzed. According to the RCA procedure, the root causes of the occurrence of the event was analyzed from the aspects of incident time sequence, fish bone map, risk prevention and control measures, tracking and evaluation. The work process was optimized, and appropriate countermeasures was developed. Basically, the occurrence of such adverse event was completely eradicated, the safety awareness of employees was improved, and the patient satisfaction level was improved.

参考文献/References:

[1]盛文佳,金可可,曹艳佩,等.根本原因分析法实践研究[J].中国卫生质量管理,2011,18(1):20-23.

更新日期/Last Update: 2017-09-28