采用根因分析法降低手术患者病理标本送检差错率的实践 - 中国护理管理.pdf

护理安全 Nursing Safety 采用根因分析法降低手术患者病理标本 送检差错率的实践 黄婷婷 李艳双 焦明丽 李思文 张婧婧 黄照权 石武祥 张晓琳 吴群红 [ 摘 要 ] 目的：探讨根因分析（RCA）法在降低手术患者病理标本送检差错率中的作用。方法：成立 RCA 小组，运用 RCA法剖析导致病理标本送检差错事件的近端原因和根本原因，制定并执行改进措施。结果：运用RCA法管理前病理标本送 检差错率为1.03%，运用后病理标本送检差错率为 0.26%，差错率明显降低；护士的各项能力得到提升。结论：RCA法是管理 手术室病理标本送检差错事件的有效方法，有利于护士的综合素质的提升和手术室患者安全目标的实现。 [ 关键词 ] 根因分析法；手术室；病理标本送检；患者安全 [中图分类号] R47 ； R197 [DOI] 10.3969/j.issn.1672-1756.2015.04.025 Revising the pathological specimen delivery errors by RCA to promote patient safety in operation room / HUANG Tingting, LI Yanshuang, JIAO Mingli, LI Siwen, ZHANG Jingjing, HUANG Zhaoquan, SHI Wuxiang, ZHANG Xiaolin, WU Qunhong // The Second Affiliated Hospital of Harbin Medical University, Harbin , 150001 China /// Chinese Nursing Management-2015,15(4): 471-474 [ ] Abstract Objective: To check out the function of Root Cause Analysis in analyzing the pathological specimen delivery errors in operating room. Methods: An RCA team was set up to analyze the proximate cause and the ultimate cause of error by using the method of RCA, and then the improved measures were proposed and carried out. Results: Before using the method of RCA, the average error rate was 1.03%. After using RCA, the average error rate dropped to 0.26%; Nurse had a positive self- assessment. Conclusion: RCA is a scientific method in the management of pathological specimen delivery flow. RCA method can not only improve the comprehensive ability of nurses ,but also can realize the goal of patient safety in operation room. [ ] Keywords Root Cause Analysis; operating room; pathological specimen