根因分析在内科住院患者跌倒风险管理中的应用分析-医学信息.PDFVIP

理研究 学信息2018 年11 月第31 卷第21 期 Medical Information Nov. 2018 Vol. 31 No.21 因分析在内科住院患者跌倒风险管理中的应用分析 宪丽 重庆医科大学附属第一医院内科袁重庆 400016冤 摘 要 目的 分析住院患者发生跌倒的原因袁探讨根因分析 RCA冤在住院患者跌倒中的应用效果遥 方法 选取我院2016 年1 月~12 月的38 起跌倒事件袁采用RCA 方法分析近端原因尧根本原因袁通过改变环境尧优化防跌倒流程尧加强人员培训等措施预 防跌倒发生袁比较实施前后患者跌倒发生率遥 结果 实施后袁跌倒发生率为0.14% 袁低于实施前的0.38% 袁差异具有统计学意义 0.05冤遥 结论 RCA 应用于内科住院患者跌倒风险管理袁对预防住院患者跌倒具有很好的 向作用遥 关键词 根因分析曰 跌倒曰 风险管理 中图分类号 R473.6 文献标识码 A DOI 10.3969/j .issn.1006-1959.2018.21.055 文章编号 1006-1959 2018冤21-0184-03 Analysis of the Application of Root Cause Analysis in Fall Risk Management of Inpatients in Internal Medicine LIU Xian-li (Department of Nephrology,the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016,China) Abstract Obj ective To analyze the causes of falls in hospitalized patients and to explore the effect of root cause analysis (RCA) on falls in hospitalized patients.Methods 38 fall events from January to December 2016 were selected. The RCA method was used to analyze the causes and root causes. The measures were taken to change the environment, optimize the fall prevention process, and strengthen personnel training to prevent falls.Compare the incidence of falls before and after implementation.Results After the implementation, the incidence of falls was 0.14% , which was lower than 0.38% before the implementation,the difference was statistically significant ( 0.05). Conclusion RCA is applied to the management of fall risk in medical inpatients and has a good guiding effect on preventing falls in hospitalized patients. Key words Root cause analysis;Fall;Risk management 跌倒是指突发、不自主、非故意的导致身体任何 无陪护 16 例。 部位（不包括双脚）的体位改变，倒在地面或比初始 1.2 方法 位置更低