CAJ | 학술논문

目的：运用RCA分析法，找出婴幼儿静脉留置针绷带固定引起压疮的根本原因制定整改措施。 　　方法：对发生静脉留置针绷带固定引起压疮的患儿临床资料采用RCA分析，找出近端原因，确定根本原因。 　　结果：造成静脉留置针绷带固定引起压疮的根本原因是护理人员主动服务意识不强，人力资源配备不足。责任护士健康教育不到位，专业知识水平掌握不够，对高危患者无风险管理意识等因素造成的。 　　结论：采用RCA分析能准确找出不良事件的根本原因，可以有效的预防再次发生类似事件。
목적：운용RCA분석법，조출영유인정맥류치침붕대고정인기압창적근본원인제정정개조시。 　　방법：대발생정맥류치침붕대고정인기압창적환인림상자료채용RCA분석，조출근단원인，학정근본원인。 　　결과：조성정맥류치침붕대고정인기압창적근본원인시호리인원주동복무의식불강，인력자원배비불족。책임호사건강교육불도위，전업지식수평장악불구，대고위환자무풍험관리의식등인소조성적。 　　결론：채용RCA분석능준학조출불량사건적근본원인，가이유효적예방재차발생유사사건。
Using RCA analysis method, find out the root cause of fixed pressure ulcers of infant venous indwel ing needle bandage formulate rectification measures. On the occurrence of venous indwel ing needle bandage caused the clinical data were analyzed by RCA to find the pressure ulcer, proximal cause, determine the root cause. The root cause of venous indwel ing needle fixed pressure ulcers bandage is nursing staff initiative service consciousness is not strong, lack of human resources. Responsibility nurse health education is not in place, not enough professional knowledge level master, factors causing no awareness of risk management for high-risk patients. RCA analysis can accurately identify the root causes of adverse events, which can effectively prevent the recurrence of similar incidents.