CAJ | 학술논문

目的：：通过对非计划性拔除气管插管事件的回顾性分析，探讨降低此类事件发生的应对措施。方法：组成根本原因分析( RCA)小组，对2010年1月~2014年3月共14例ICU患者发生非计划性拔除气管插管的事件进行RCA分析，找到近端原因和根本原因。结果：系统原因是ICU非计划性拔除气管插管的根本原因。结论：改善约束材料，增加医护沟通，强化培训教育，实行预警教育，可防范ICU非计划性拔除气管插管的发生。
목적：：통과대비계화성발제기관삽관사건적회고성분석，탐토강저차류사건발생적응대조시。방법：조성근본원인분석( RCA)소조，대2010년1월~2014년3월공14례ICU환자발생비계화성발제기관삽관적사건진행RCA분석，조도근단원인화근본원인。결과：계통원인시ICU비계화성발제기관삽관적근본원인。결론：개선약속재료，증가의호구통，강화배훈교육，실행예경교육，가방범ICU비계화성발제기관삽관적발생。
Objective:Patients with unplanned extubation in the ICU were analysed retrospectively to explore the mesures to prevent occurrences of the such incidents. Methods:A total of 14 patients in ICU with unexpected extubation events from January 2010 to March 2014,were analysed by the root cause analy-sis ( RCA) group to find the basic reason of the events. Results:The system fctors were the fundamental cause of the unplanned extubation in ICU patients. Conclusion:The use of appropriate binding materials,strengthen the medical communication,improve training and education and implementation of early warning education,can prevent occurrence of unplanned extubation in ICU.