根本原因分析法在降低留置导尿患者拔除尿管后尿潴留事件中的应用

摘要

目的：探讨根本原因分析法（RCA）在降低留置导尿患者拔除尿管后尿潴留事件中的应用及效果。方法：成立RCA小组，收集相关数据资料，采用鱼骨图找出拔除尿管后发生尿潴留的近端原因，确定根本原因，制订并实施改进措施，比较应用RCA前后的效果。结果：应用RCA后，留置导尿患者拔除尿管后尿潴留发生率由17.65%下降至6.37%，患者满意度由83.33%提高至94.55%，实施前后比较差异均有统计学意义（P<0.05）。结论：RCA可有效降低留置导尿患者拔除尿管后尿潴留发生率，提升护理质量，提高患者满意度，促进小组成员自身成长。%Objective:To explore the effect of root cause analysis(RCA)in reducing the incident of urine retention after catheter removal among patients with indwelling catheter. Method:RCA group was established,the related data were collected,the fishbone diagram was used to identify the immediate causes of the incident of urine retention after catheter removal,the root causes were determined,then improvement measures were developed and implemented,and the effects before and after the application of RCA were compared. Result:After implementation the method of RCA,the incidence of urine retention after catheter removal among patients with indwelling catheter decreased from 17.65%to 6.37%,the patients’ satisfaction improved from 83.33%to 94.55%,the difference was statistically significant(P<0.05). Conclusion:The application of RCA can effectively reduce the incidence of urine retention after catheter removal among patients with indwelling catheter,improve the quality of nursing and patients’satisfaction and promote the development of the group members.