CAJ | 학술논문

目的探讨根本原因分析法(RCA)在儿科输液不良事件管理中的应用,以改善儿科输液不良事件发生情况.方法 2011年4-9月病区实施RCA前及2011年10月至2012年3月病房实施RCA后分别统计病区输液不良事件发生率、双人核对落实率及输液速度准确率.比较实施RCA前后效果.结果实施RCA后6个月输液不良事件发生率为0.03％,低于实施RCA前6个月的0.32％,差异有统计学意义(x2=19.146,P＜0.01)；实施RCA后护士双人核对落实率及输液速度准确率分别为100％,98％,均高于实施RCA前的74％,83％,差异均有统计学意义(x2分别为29.885,13.085;P＜0.01).结论在输液不良事件管理中实施RCA能有效控制影响输液安全的主要影响因素,降低输液不良事件发生率,提高输液安全.
목적 탐토근본원인분석법(RCA)재인과수액불량사건관리중적응용,이개선인과수액불량사건발생정황.방법 2011년4-9월병구실시RCA전급2011년10월지2012년3월병방실시RCA후분별통계병구수액불량사건발생솔、쌍인핵대락실솔급수액속도준학솔.비교실시RCA전후효과.결과 실시RCA후6개월수액불량사건발생솔위0.03％,저우실시RCA전6개월적0.32％,차이유통계학의의(x2=19.146,P＜0.01)；실시RCA후호사쌍인핵대락실솔급수액속도준학솔분별위100％,98％,균고우실시RCA전적74％,83％,차이균유통계학의의(x2분별위29.885,13.085;P＜0.01).결론 재수액불량사건관리중실시RCA능유효공제영향수액안전적주요영향인소,강저수액불량사건발생솔,제고수액안전.
Objective To investigate the application of root cause analysis (RCA) in the management of pediatric transfusion adverse events,in order to reduce the occurrence rate of adverse events in pediatric transfusion.Methods Root cause analysis method was used from October 2011 to March 2012.Occurrence rate of adverse events,double check and accuracy of transfusion were compared before and after the implementation of RCA.Results Six months before RCA,the occurrence rate of adverse events was 0.32％ and six months after RCA was 0.03％,and the difference was statistically significant (x2 =19.146,P ＜ 0.01).The rate of double check and accuracy of transfusion were respectively 100％ and 98％ after RCA,which were higher than those before RCA (74％ and 83％),and the differences were statistically significant (x2 =29.885,13.085,respectively; P ＜ 0.01).Conclusions Root cause analysis can effectively control related factors during pediatric transfusion,reduce the occurrence rate of adverse events and improve transfusion safety.