主管:国家卫生健康委员会
主办:国家卫生计生委医院管理研究所
中国科学引文数据库(CSCD)来源期刊
中国科技论文统计源期刊 中国科技核心期刊
《中文核心期刊要目总览》入选期刊

Chinese Nursing Management ›› 2022, Vol. 22 ›› Issue (12): 1866-1871.doi: 10.3969/j.issn.1672-1756.2022.12.021

• Nursing Safety • Previous Articles     Next Articles

Root Cause Analysis in the improvement of identification process of day surgery patients

LU Zhenling, YANG Xinyu, MA Bing, WANG Bingzheng, YUAN Li, PEI Yuquan   

  1. Anesthesiology and Operating Department II, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, China
  • Online:2022-12-15 Published:2022-12-15
  • Contact: E-mail:yq031224@sina.com

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

CLC Number: R47;R197