39例温针灸烫伤的原因分析及管理改进建议详解.PDFVIP

护理安全 Nursing Safety 专栏 39例温针灸烫伤的原因分析及管理 改进建议 庄君贤 钟印芹 刘牧军 [ 摘 要 ] 目的：探讨温针灸烫伤根本原因及管理改进措施。方法：应用根本原因分析法对 39 例温针灸烫伤事件进行原 因分析，识别风险因素，找出根本原因，制订整改措施，并与整改措施实施后的温针灸烫伤率进行对比分析。结果：整改措施 实施前后烫伤发生率比较差异有统计学意义，整改措施实施后温针灸烫伤率明显降低，差异有统计学意义（P0.01）。结论： 进行温针灸烫伤的原因分析，有助于制定整改措施，降低了温针灸烫伤的发生率，促进了温针灸治疗的安全管理和护理质量的 持续改进。 [ 关键词 ] 温针灸；烫伤；根本原因分析 [中图分类号] R47 [DOI] 10.3969/j.issn.1672-1756.2015.01.022 The application of Root Cause Analysis on the management of 39 burns in acupuncture with warming needle / ZHUANG Junxian, ZHONG Yinqin, LIU Mujun // Outpatient Department, Shenzhen Futian Hospital of TCM, Shenzhen, Guangdong province, 518034 China /// Chinese Nursing Management-2015,15(1): 72-74 [Abstract] Objective: To explore the effect of Root Cause Analysis on the management of burns in acupuncture with warming needle. Methods: We analyzed the reasons of 39 burns in acupuncture with warming needle by Root Cause Analysis, identified the risk factors, found out basic reason, took corrective measures, and compared the effect before and after the implementation of the corrective measures. Results: The incidence of burns reduced significantly after the implementation of corrective measures (P0.01). Conclusion: Root Cause Analysis and corrective measures are effective for safety management of burn in acupuncture with warming needle and help to reduce the incidence of burn and to improve nursing quality continuously. [Keywords] acupuncture with warming needle; burn; root cause analysis 温针灸烫伤是患者在温针灸治疗过 率，现报道如下。 过程重点了解和记录护理操作的流程， 程中发生的皮肤烫伤。温针灸是针刺与 1 一般资料 艾柱的切制要求与固定方法，健康宣 艾灸相结合的一种针灸疗法 [1] ，通常是 教情况，温针灸烫伤事件的具体原因、 2012 年10-12月，我院针灸科门诊 在医生行针刺留针后，再由护士进行的