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[1]匡芸芸彭涛何永琴易德坤周媛媛张峡张玉梅陈锦.老年全髋关节置换患者居家康复期假体脱位事件的持续改进[J].中国卫生质量管理,2025,32(09):27-34.[doi:10.13912/j.cnki.chqm.2025.32.9.06]
　KUANG Yunyun,PENG Tao,HE Yongqin.Continuous Improvement of Prosthetic Dislocation Incidents in Elderly Patients During Home-Based Rehabilitation after Total Hip Arthroplasty[J].Chinese Health Quality Management,2025,32(09):27-34.[doi:10.13912/j.cnki.chqm.2025.32.9.06]

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老年全髋关节置换患者居家康复期假体脱位事件的持续改进

《中国卫生质量管理》[ISSN:1006-7515/CN:CN 61-1283/R] 卷: 32 期数: 2025年09期页码: 27-34 栏目: 特别关注出版日期: 2025-09-15

Title:: Continuous Improvement of Prosthetic Dislocation Incidents in Elderly Patients During Home-Based Rehabilitation after Total Hip Arthroplasty

作者:: 匡芸芸彭涛何永琴易德坤周媛媛张峡张玉梅陈锦; 陆军军医大学第二附属医院

Author(s):: KUANG Yunyun; PENG Tao; HE Yongqin; The Second Affiliated Hospital of Army Military Medical University

关键词:: 根本原因分析; 整合型RCA; 老年患者; 全髋关节置换术; 假体脱位; 居家康复期; 患者安全

Keywords:: Root Cause Analysis; Integrated RCA; Elderly Patients; Total Hip Arthroplasty; Prosthetic Dislocation; Home-Based Rehabilitation; Patient Safety

分类号:: R197.323；R684

DOI:: 10.13912/j.cnki.chqm.2025.32.9.06

文献标志码:: B

摘要:: 目的探讨老年全髋关节置换患者居家康复期假体脱位的防控策略，为居家安全管理提供参考。方法成立RCA团队，应用整合型RCA进行事件调查与分析，建立基于福格行为模型的防脱位行为设计、构建核心照护者管理方案、优化围手术期防脱位管理制度3大改善方案。结果老年全髋关节置换患者术后3个月假体脱位发生率由1.82%降低为0.20%，防脱位措施执行正确率由95.30%提升至99.80%，关键环节全程陪护在位率由65.10%提升至94.96%，居家环境合格率由82.55%提升至95.56%，实现了老年全髋关节置换患者居家康复期安全管理的目标。结论应用整合型RCA可有效探寻多例连续发生的同类型不良事件的系统根因并针对性改进，有利于强化事前风险管理，增强团队合作，建立组织质量安全文化，从而保障患者安全。

Abstract:: ObjectiveTo explore the prevention and control strategies for prosthetic dislocation in elderly patients undergoing total hip arthroplasty (THA) during home-based rehabilitation, providing references for home safety management.MethodsAn Root Cause Analysis (RCA) team was established, and an integrated RCA approach was applied to investigate and analyze events. Three improvement strategies were developed: designing anti-dislocation behaviors based on the Fogg Behavior Model, constructing a core caregiver management plan, and optimizing the perioperative anti-dislocation management system for THA. ResultsThe incidence of prosthetic dislocation in elderly THA patients three months postoperatively decreased from 1.82% to 0.20%. The correct implementation rate of anti-dislocation measures increased from 95.30% to 99.80%. The full-time attendance rate of caregivers during critical stages rose from 65.10% to 94.96%. The compliance rate of home environment standards improved from 82.55% to 95.56%, achieving the goal of safe home-based rehabilitation management for elderly THA patients. Conclusion The application of integrated RCA can effectively identify systemic root causes of multiple consecutive adverse events of the same type and facilitate targeted improvements, thereby strengthening proactive risk management, enhancing team collaboration, and fostering an organizational culture of quality and safety to ensure patient safety.

参考文献/References:

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更新日期/Last Update: 2025-09-15