CAJ | 학술논문

目的：探索根因分析法预防老年外科高危患者各类留置管道非计划性拔管的效果，以期提高患者住院期间的安全性.方法通过根因分析对老年外科高危患者各种留置管道非计划性拔管事件进行原因分析找出可能原因，遵照解放军总医院十项护理核心制度，加强其中值班交接班制度、分级护理巡视制度、护理安全评估及报告制度、使用约束患者管理制度等的执行力度，改善留置各类管道及约束具的固定方法，针对相关陪护人员进行更完善的训练，提高医护患间的沟通与合作等符合临床实际需求、个性化的整改措施，并与整改措施实施后的观察组进行对比分析.结果2009年7月至2011年7月各类留置管道非计划性拔管由5．0％下降到2011年7月至2013年7月的2．5％，差异有统计学意义(P＜0．01).结论根据老年外科高危患者的特点，严格落实各项制度的执行，加强各方沟通，设计及执行改善的行动计划，有效地降低了各类管道滑脱的发生率.
목적：탐색근인분석법예방노년외과고위환자각류류치관도비계화성발관적효과，이기제고환자주원기간적안전성.방법통과근인분석대노년외과고위환자각충류치관도비계화성발관사건진행원인분석조출가능원인，준조해방군총의원십항호리핵심제도，가강기중치반교접반제도、분급호리순시제도、호리안전평고급보고제도、사용약속환자관리제도등적집행력도，개선류치각류관도급약속구적고정방법，침대상관배호인원진행경완선적훈련，제고의호환간적구통여합작등부합림상실제수구、개성화적정개조시，병여정개조시실시후적관찰조진행대비분석.결과2009년7월지2011년7월각류류치관도비계화성발관유5．0％하강도2011년7월지2013년7월적2．5％，차이유통계학의의(P＜0．01).결론근거노년외과고위환자적특점，엄격락실각항제도적집행，가강각방구통，설계급집행개선적행동계화，유효지강저료각류관도활탈적발생솔.
Objective To explore the effect of root cause analysis in the prevention of unplanned extubation in elderly surgical patients at high-risk with indwelling tube,in order to improve patient safety during hospi-talization.Methods The root cause analysis method used to analysis data from elderly surgical patients at high risk of unplanned extubation various events to identify influencing factors.According to our hospital’s ten core nursing care system,we enforced duty shift system,grading and inspection nursing system,safety assessment and reporting system,management of restraint usage system.We improved the fixing methods of pipelines constraints and training of the relevant accompanying personnels,and also pay more attention to communication and cooperation between healthcare personnels and patients,and individualized rectification measures.The effects of above prevention strategies were compared with the observation group at the end of this study.Results From July 2 0 0 9 to July 2 0 1 1 ,the incidence of unplanned indwelling pipelines extuba-tion was 5 .0%,and decreased to 2 .5% from July 2 0 1 1 to July 2 0 1 3 after prevention strategies were taken (P<0 .0 1 ).Conclusion Based on the characteristics of elderly surgical patients at high risk,strict imple-mentation of the system execution,strengthen communication between the patients and healthcare person-nels,improvement of the design and implementation of action,these prevention strategies effectively reduced the risks of unplanned indwelling pipelines extubation.