[1]谢大玲李君慧肖代梅袁偲旖侯静张方玲陈航.1例晨间集中静脉血标本采集错误的根因分析与改进[J].中国卫生质量管理,2021,28(02):047-49.[doi:10.13912/j.cnki.chqm.2021.28.2.15 ]
　XIE Daling,LI Junhui,XIAO Daimei.Root Cause Analysis and Improvement of an Incident of Erroneous Collection of Venous Blood Samples in the Morning[J].Chinese Health Quality Management,2021,28(02):047-49.[doi:10.13912/j.cnki.chqm.2021.28.2.15 ]
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1例晨间集中静脉血标本采集错误的根因分析与改进
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《中国卫生质量管理》[ISSN:1006-7515/CN:CN 61-1283/R]

卷:
第28卷
期数:
2021年02期
页码:
047-49
栏目:
患者安全
出版日期:
2021-02-28

文章信息/Info

Title:
Root Cause Analysis and Improvement of an Incident of Erroneous Collection of Venous Blood Samples in the Morning
作者:
谢大玲李君慧肖代梅袁偲旖侯静张方玲陈航
广安市人民医院
Author(s):
XIE Daling; LI Junhui; XIAO Daimei
Guang'an People's Hospita
关键词:
静脉血标本; 采集; 根本原因分析; 患者安全
Keywords:
Venous Blood Sample; Collection;  Root Cause Analysis;  Patient Safety
分类号:
R197.32
DOI:
10.13912/j.cnki.chqm.2021.28.2.15
文献标志码:
B
摘要:
对１例晨间集中静脉血标本采集错误事件展开根本原因分析。通过原因挖掘，从建立晨间集中静脉血标本采集质量三级督导及考核机制，规范并落实晨间集中静脉血标本采集班次核查标准，以问题为导向规范护理实习生带教管理等方面加以改进，取得了较好效果。建议：患者参与患者安全管理，医务人员应加强查对制度落实并重视教学管理，医院应加强安全监管与督导，不断优化管理制度和流程。
Abstract:
The root cause analysis was carried out for a case of erroneous collection of venous blood in the morning. Through the cause excavation, improvements were made from aspects of establishment of a three-level supervision and assessment mechanism for the collection quality of concentrated venous blood in the morning; standardizing and implementing the inspection standard for the shift of collection of venous blood samples in the morning; taking the problem as the guidance, standardizing the teaching management of nursing interns, which achieved good results. It suggested that patients should participate in patient safety management, medical staff should strengthen the implementation of inspection system and pay attention to teaching management, hospital should strengthen safety supervision and supervision, and constantly optimize the management system and process.

参考文献/References:

［1］张菀楠.一种新型采血样本收集板的设计［J］.护士进修杂志,2018,33(20):1918-1919. ［2］姜岩涛.30例血液标本不合格原因及对策分析［J］.吉林医学，2013,34(26):5504-5505. ［3］吴媛媛，安晓霞，赵云萍，等．血液标本采集影响检验结果的原因分析及对策［J］.临床合理用药杂志，2012,5(10):8-14. ［4］吴建瑜.对1起输错血浆事件的根本原因分析［J］.中华护理杂志,2013,48(10):917-919. ［5］Kung JW, Brook OR, Eisenberg RL, et al. How-I-Do-It: Teaching root cause analysis［J］.Acad Radiol, 2016,23(7):881-884. ［6］The Joint Commission. Sentinel event policy and procedure［EB/OL］. (2019-08-08)［2020-05-05］.https://www.jointcommission.org/sentinel_event_policy_ and_procedures/. ［7］李梦玲, 王富兰, 肖明朝,等. 1例给药错误的根本原因分析［J］.中国卫生质量管理, 2019, 26(2):58-61. ［8］唐新,贾克刚,李秀良,等. 1例血小板输错事件的根本原因分析［J］.中国卫生质量管理, 2016，23(2):13-15. ［9］Brook OR, Kruskal JB, Eisenberg RL, et al. Root cause analysis: Learning from adverse safety events［J］.Radiographics, 2015,35(6): 1655-1667. ［10］朱云霞,王平侠,冯瑞,等.特性要因图与五问法分析住院患者跌倒原因实践及启示［J］.护理学杂志，2014,29(19):40-42. ［11］李远珍,王聪智,汪苗,等.我国患者参与患者安全的研究现状及启示［J］.牡丹江医学院学报,2019,40(6):130-132.

相似文献/References:

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　ZHOU Chun,NAN Min,WANG Jing.Informatization of Quality Management before Blood Collection[J].Chinese Health Quality Management,2021,28(02):080.[doi:10.13912/j.cnki.chqm.2021.28.10.21 ]

更新日期/Last Update: 2021-02-28