关键词: 根本原因分析法；手术室；坠床；不良事件分析

Abstract: Objective: To investigate the effect of Root Cause Analysis (RCA) in the management of patients falling from bed in the operating room. Methods: An RCA team was established to collect relevant information of patients' falls through interviewing and site investigation to chronologically display the whole process of the falling events in operating room, identify the recent causes to determine the root cause using fishbone diagram analysis, so that a better action plan could be implemented to evaluate the effectiveness. Results: After the implementation of the improvement action, the rate of properly using restraint belts, the rate of finishing surgical safety training, and the ratio of falling signs all reached 100%. Conclusion: The application of RCA to analyze patient' falling from bed in the operating room is helpful to enhance the safety system of the hospital, strengthen medical staff's safety awareness to improve medical quality and ensure patient safety.

Key words: Root Cause Analysis; operating room; falling from bed; analysis of adverse events