根本原因分析法在降低手术室护理不良事件中的应用

摘要

Objective To explore the effect of fundamental causes analyzing on reduction of nursing defects in operation room. Methods The method of fundamental causes analyzing was adopted to find out the causes of nursing defects in the operation room during January 2008 to December 2009. The measures were worked out and the nursing defects in the room were recorded and analyzed after the countermeasures were taken. Result The nursing defects fell from 62 cases to 6 cases in the operation room. Conclusion The method of fundamental causes analyzing, together with the countermeasures may be effective in reducing the nursing defects in operation room and thus improving the nursing quality.%目的 探讨根本原因分析法在降低手术室护理不良事件中的应用.方法 应用根本原因分析法对2008年1月～2009年12月本院手术室发生的护理不良事件进行分析,找出事件的主要问题和症结,讨论导致事件的根本原因,制订和执行改进措施.观察执行改进措施两年后,手术室护理不良事件的发生情况.结果 手术室护理不良事件的发生从62件下降至6件.结论 运用根本原因分析法对手术室护理不良事件进行分析,制订和执行改进措施,有效地降低了护理不良事件的发生,从而提高了手术室护理质量.