CAJ | 학술논문

目的：探讨应用根源性分析(RCA）结合质量环管理法(PDCA)预防护理安全隐患的效果。方法：2012年实行PDCA循环管理法，2013年在PDCA基础上实行RCA，提出改进措施或修改流程，建立完善的预防及处理评估流程。结果：横向观察，2013年与2012年相比护理安全隐患上报例数增加，护理差错发生例数减少，且同一差错发生率降低；纵向观察，2013年较2012年护理差错有下降趋势。结论：RCA与PDCA管理法相结合，在持续护理质量改进的循环中分析确定根本原因，能够有效解决质量问题并且预防同类不良事件的发生，取得治标更治本的管理效应。
목적：탐토응용근원성분석(RCA）결합질량배관리법(PDCA)예방호리안전은환적효과。방법：2012년실행PDCA순배관리법，2013년재PDCA기출상실행RCA，제출개진조시혹수개류정，건립완선적예방급처리평고류정。결과：횡향관찰，2013년여2012년상비호리안전은환상보례수증가，호리차착발생례수감소，차동일차착발생솔강저；종향관찰，2013년교2012년호리차착유하강추세。결론：RCA여PDCA관리법상결합，재지속호리질량개진적순배중분석학정근본원인，능구유효해결질량문제병차예방동류불량사건적발생，취득치표경치본적관리효응。
Objective:To explore the effects of root cause analysis (RCA) combined with Plan-do-check-ac-tion (PDCA) cycle in preventing the potential nursing safety hazards. Methods:With the PDCA cyclic management law executed in 2012, the RCA was performed in 2013 and the improvement measures or modification processes were put forward to establish a sound prevention system and processes of managing evaluations. Results:By trans-verse observation, compared with 2012, the number of the potential nursing safety hazards reported in 2013 in-creased, so that the number of nursing errors decreased and the incidence of the same error reduced;through longitu-dinal observation, the number of nursing errors in 2013 showed the tendency of declining in comparison of that in 2012. Conclusion:Since the qualities of continued nursing are improved in a cycle to analyze and define the radical reasons, the combination of RCA and PDCA management can effectively improve the nursing quality and prevent the occurrence of similar adverse events to obtain the management effects of not only temporarily treating but also treating root causes.