根因分析法在降低Braden评分不超过16分的老年患者压疮发生率中的应用研究

摘要

Objective To study the effect of root cause analysis on reducing the incidence of pressure ulcer in elderly patients with Braden score of less than 16.Method Root cause analysis team was established,12 cases of elderly patients with pressure ulcers from April to May of 2015 were tracked one by one using root cause analysis method to investigate the causes of pressure sores,then find out the reason of the proximal end,analyze the root cause,and make a series of improvement measures.And in 2015 7-9 months in 228 cases of Braden score of not more than 16 points in the elderly patients,before and after the implementation of the pressure ulcer incidence rate.The pressure ulcer incidence rate for 228 elderly patients with Braden score less than 16 points from July to September 2015 was studied before and after the implementation.Results The pressure ulcer incidence for elderly patients with Braden scale less than 16 was reduced from former 6.06 ％ to 2.19％ after nursing intervention.Conclusion The root cause analysis can be effective for the skin safety management for elderly patients with the Braden score less than 16 points,reduce the incidence of pressure ulcers and improve the quality of nursing.%目的 探讨根因分析法对降低Braden评分不超过16分的老年患者压疮发生率的效果.方法 成立根因分析小组,运用根因分析法对2015年4-5月发生在老年科的12例压疮患者逐一进行追踪,调查导致患者发生压疮的原因,寻找近端原因、剖析出根本原因,进而制订改进措施并实施于2015年7-9月的228例次Braden评分不超过16分的老年患者.比较实施前后患者压疮发生率.结果 通过护理干预,Braden评分不超过16分的老年患者压疮发生率从开展前的6.06％降到开展后的2.19％,差异有统计学意义(P＜0.01).结论 采用根因分析法可以有效对Braden评分不超过16分的老年患者的皮肤进行安全管理,从而降低老年患者压疮发生率,提升护理质量.