根本原因分析法（RCA）在医疗不良事件分析中的应用

摘要

Root cause analysis is a retrospective mistake analysis method which is an important method on promoting patient safety accepted by internal community. The basic principles, processes and cases of applying root cause analysis are discussed. It shows that root cause analysis can help hospital finding mistake and hidden risk in business process and organization structure and carrying out countermeasures to improve medical staffs’ safety awareness and build safety culture.%根本原因分析法(Root CauseAnalysis，RCA)是一种回溯性失误分析方法，被国际医疗界认为是提升病人安全的重要方法之一。本文阐述了RCA的基本原理和执行步骤，并以案例应用形式进行辅助说明，提出RCA能改变传统管理方式中只针对单一事件治标不治本的管理漏洞，可以协助医院找出工作流程中及系统设计上存在的缺点和风险，并采取正确的措施加以完善，从而提高医护人员的安全责任意识，在医院内营造一种良好的安全文化。