采用根因分析法降低手术患者病理标本送检差错率的实践

采用根因分析法降低手术患者病理标本送检差错率的实践

黄婷婷李艳双焦明丽李思文张婧婧黄照权石武祥张晓琳吴群红

哈尔滨医科大学附属第二医院手术室

出版日期:2015-04-25 发布日期:2015-04-25
基金资助:
国家自然科学基金（70903019，71273002）；教育部人文社科研究专项任务（12JDGC005）；黑龙江优秀人才培养计划（1252-NCET-020）；联合保险经纪集团公司及哈尔滨医科大学医疗风险管理研究所联合资助

Revising the pathological specimen delivery errors by RCA to promote patient safety in operation room

Online:2015-04-25 Published:2015-04-25

摘要/Abstract

摘要： 目的：探讨根因分析（RCA）法在降低手术患者病理标本送检差错率中的作用。方法：成立RCA 小组，运用RCA 法剖析导致病理标本送检差错事件的近端原因和根本原因，制定并执行改进措施。结果：运用RCA 法管理前病理标本送检差错率为1.03%，运用后病理标本送检差错率为0.26%，差错率明显降低；护士的各项能力得到提升。结论：RCA 法是管理手术室病理标本送检差错事件的有效方法，有利于护士的综合素质的提升和手术室患者安全目标的实现。

Abstract: Objective: To check out the function of Root Cause Analysis in analyzing the pathological specimen delivery errors in operating room. Methods: An RCA team was set up to analyze the proximate cause and the ultimate cause of error by using the method of RCA, and then the improved measures were proposed and carried out. Results: Before using the method of RCA, the average error rate was 1.03%. After using RCA, the average error rate dropped to 0.26%; Nurse had a positive selfassessment.Conclusion: RCA is a scientific method in the management of pathological specimen delivery flow. RCA method can not only improve the comprehensive ability of nurses ,but also can realize the goal of patient safety in operation room.

黄婷婷李艳双焦明丽李思文张婧婧黄照权石武祥张晓琳吴群红. 采用根因分析法降低手术患者病理标本送检差错率的实践[J]. , 2015, 15(4): 471-474.