CAJ | 학술논문

目的：为医院管理者应用RCA品质改善手法的运用提供借鉴。方法根据现实的案例(异丙嗪特殊给药途径用药途径错误导致患者意识改变)应用RCA手法进行对案例分析，提出改进建议进行品质改善。结果2012年6月~2014年1月期间医院未发生因为特殊给药途径的药物用药途径错误的现象。结论运用RCA手法能找出事件的系统原因，剖析原因采取相应的实际行动来加以改进，并分享案例改进方法，杜绝此类事件的再发生。
목적：위의원관리자응용RCA품질개선수법적운용제공차감。방법근거현실적안례(이병진특수급약도경용약도경착오도치환자의식개변)응용RCA수법진행대안례분석，제출개진건의진행품질개선。결과2012년6월~2014년1월기간의원미발생인위특수급약도경적약물용약도경착오적현상。결론운용RCA수법능조출사건적계통원인，부석원인채취상응적실제행동래가이개진，병분향안례개진방법，두절차류사건적재발생。
Objective To offer reference that the hospital governors use RCA quality improvement method. Methods Carries on the case analysis according to the case using RCA methods of reality, such as promethazine special to the wrong medicine drug approaches pathways leading to patient consciousness change, put forward the improvement pro-posal for quality improvement. Results During the period from June 2012 to January 2014 , the hospital did not happen because the drugs special route of administration way wrong phenomenon. Conclusion Application of RCA techniques can help us find the system reasons for the incident, and then analyze the reasons, to take practical action to improve the corresponding. And share the case method, put an end to these events.