关键词: 根本原因分析法；日间手术；患者身份识别；不良事件分析

Abstract: Objective: To analyze the effects of Root Cause Analysis (RCA) applied in improving the identification process of day surgery patients. Methods: Established an RCA group to collect event-related information, restored the event process through the time sequence list, found the proximal cause, analyzed and determined the root cause by the problem tree and fishbone diagram, performed barrier assays, formulated and implemented improvement action schedule, then evaluated the effects. Results: After the implement of improvement action, the incidence of irregular identity verification for the preoperative patients decreased significantly (P<0.05). The temporary adjustment rate of operating table also significantly decreased (P<0.05). The ratio of paying outpatient examination fee during pre-hospitalization with health insurance, completion rate of relevant personnel day surgery operation process training, usage rate of electronic surgery notice, correct rate of sign placement and accuracy rate of patient identification all achieved 100%. Conclusion: Applicating RCA to analyze the surgical patient identification error can better help identify system defects in the operating room workflow, identify root cause, formulate action improvement plan, improve medical quality, and ensure patient safety.

Key words: Root Cause Analysis; day surgery; patient identification; adverse event analysis