应用根本原因分析法减少新生儿科高危药物外渗及损伤的-中国护理管理.PDFVIP

护理安全 Nursing Safety 百特 专栏 应用根本原因分析法减少新生儿科高危 药物外渗及损伤的实践 阮景 潘继红 [ 摘 要] 目的：探讨根本原因分析法（RCA) 在减少新生儿科高危药物外渗及损伤中的作用。方法：对 2011年2281例发生 静脉输液高危药物外渗的案例进行根本原因分析，并制定改进措施；分析 RCA实施前(2011年1-12月) 与实施后 (2012 年1-12 月)高危药物外渗发生率与程度。结果：RCA实施后高危药物外渗率及损伤率低于实施前，差异有统计学意义（P0.01）。结论： 运用根本原因分析法能有效找到引起药物外渗及损伤的根本原因，采取相应的措施，提高新生儿科静脉输液的安全性。 [ 关键词 ] 根本原因分析法；高危药物；静脉输液；外渗；损伤 [中图分类号] R47 [DOI] 10.3969/j.issn.1672-1756.2013.010.023 The effect of Root Cause Analysis on reducing the high-risk drug exosmosis and injury in neonatal department / RUAN Jing, PAN Ji-hong // Nursing Department, Guangdong Woman and Children Hospital, Guangzhou, 511400 China /// Chinese Nursing Management- 2013,13(10): 64-66 [Abstract] Objective: To explore the effect of Root Causes Analysis (RCA) on reducing the high-risk drug exosmosis and injury in neonatal department. Methods: We adopted RCA to find out the root causes of exosmosis and injury in the treatment of neonates during 2011 and draw up the corresponding corrective measures. We compared the differences of the exosmotic rate and injury extent between the year 2011 (before RCA) and year 2012 (after RCA). Results: The rates of exosmosis and injury after RCA were significantly lower than those before RCA (P0.01). Conclusions: The application of RCA could find the root causes of exosmosis and injury. We could take effective measures to improve intravenous transfusion safety in neonatal department. [Key words] Root Causes Analysis; high risk drug; intravenous infusion; exosmosis; injury 静脉输液是新生儿科进行临床治疗 1 资料与方法 副主任护师 2人，主管护师 4人，护师 的常用手段，而由于新生儿的生理解剖 1.1 一般资料 3人。 特点，使其在输液过程中容易发生药物 我院新生儿科2011年执行高危药物 1.2.2 实施 RCA，确认根本原因 外渗现象，并且主要依赖护士巡查才能 静脉治疗的患者人数为2637人，总例数 在充分收集药物外渗相关资料后，采 发现，有时会错