基于根本原因分析法的不良事件改进

摘要

成立RCA小组,对两起给药错误事件展开根本原因分析,梳理流程,针对性提出改进方案.两起不良事件发生均有多种影响因素,包括医生、护士、药剂师及电脑程序缺陷等.其中,电脑程序缺陷是根本原因,通过改进,完善了软件程序,避免了类似事件的再发生.认为RCA是分析不良事件,提高医疗安全水平的有效工具.%The RCA group was established to analyze the root cause of two cases of adverse events of drug mistake,make clear the process,and put forward the improvement program.The two adverse events had various influencing factors,including doctors,nurses,pharmacists and computer bugs,etc.,among which the computer program defect was the root cause.Through the improvement,the software program was improved to avoid similar events happen again.RCA is an effective tool to analyze adverse events and improve medical safety.