Efficacy of Root Cause Analysis on the Management of Adverse Nursing Events in the Infusion Room of the Department of Pediatrics_West China Medical Journal

Authors：

 HouYan , JinXiaoping

Department of Pediatrics, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, Xinjiang 830001, P. R. China;

Corresponding?author：

Keywords：

Root cause analysis; Adverse nursing events; Safety management

DOI：

10.7507/1002-0179.20160094

Video：

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Objective To explore the application and effect of root cause analysis (RCA) in the management of adverse nursing events. Methods Nursing staff members were trained to establish the team of root cause analysis. They collected related materials of adverse nursing events in the infusion room of the Department of Pediatrics, found out the proximal causes and root causes, developed and implemented the corrective measures. RCA was carried out between January 2013 and December 2014. The efficacy was evaluated and the adverse events rate was compared before and after the practice. Results After the performance of RCA, the reporting rate of adverse events increased, the rate of adverse events decreased, and the reporting rate of potential safety problems also increased. All those changes were significant (P<0.01). Conclusion Root cause analysis can decrease the rate of adverse nursing events, raise the reporting rate of adverse events. It is an effective guarantee to improve the nursing safety management.

Citation： HouYan, JinXiaoping. Efficacy of Root Cause Analysis on the Management of Adverse Nursing Events in the Infusion Room of the Department of Pediatrics. West China Medical Journal, 2016, 31(2): 351-354. doi: 10.7507/1002-0179.20160094 Copy

1.	任仲杰. 美國的醫療差錯和不良事件報告系統[J]. 中華醫院管理雜志, 2006, 22(6):425-427.
2.	Haimen. Roots analys is for injury prevention and control[J]. Am Navy, 1987, 34(7):431-445.
3.	Leape Ⅱ. Error inmedicine[J]. JAMA, 1994, 272(23):1851-1857.
4.	Dew JR. Using root cause analysis to make the patient care system safe[C]//Proceedings of the 56th Annual Quality Congress in Denver. Denver:Annual Quality Congress, 2002:651-655.
5.	Eagle CJ, Davies JM, Reason J. Accident analysis of large-scale technological disasters applied to an anaesthetic complication[J]. Can J Anaesth, 1992, 39(2):118-122.
6.	Dixon JF, Wielgosz C, Pires ML. Description and outcomes of acustom web-based patient occurence reporting system developedfor baylor university medical center and other system entities[J]. Proc (Bayl Univ Med Cent), 2002, 15(2):199-202.
7.	陳梅花, 黃寶珠, 李敏紅, 等. 護生靜脈輸液的細節管理[J]. 護理學報, 2012, 19(2):29-31.
8.	梁麗云, 周望梅. 門診靜脈輸液患者配合實習護生操作意愿調查分析[J]. 護理學報, 2012, 19(8):32-35.
9.	吳慶錕. 根本原因分析法在護患糾紛中的應用[J]. 中國當代醫藥, 2012, 19(2):140-141.
10.	韓光曙. 醫院的安全文化與醫療安全[J]. 中華醫院管理雜志, 2004, 20(3):129-131.
11.	Notan TW. System changes to improve patient safety[J]. BMJ, 2000, 320(7):771-773.
12.	王玲, 張艷. 護士在無責呈報制度下主動呈報不良事件的現狀分析及對策[J]. 護理管理雜志, 2009, 9(7):46-47, 56.
13.	鄭華蓉, 黃祥智. 實施免責法護理缺陷上報機制打造護理安全文化[J]. 護理學報, 2012, 19(7):36-38.
14.	林玉丹, 李麗香, 沈秋鳳, 等. 根本原因分析法在成批燒傷病人早期救治質量控制中的應用[J]. 護理研究, 2013, 27(20):2158-2159.
15.	周萍, 魏群. 根本原因分析法在社區血脂異常居民健康管理中的應用[J]. 全科護理, 2014, 12(11):970-971.

1. 任仲杰. 美國的醫療差錯和不良事件報告系統[J]. 中華醫院管理雜志, 2006, 22(6):425-427.
2. Haimen. Roots analys is for injury prevention and control[J]. Am Navy, 1987, 34(7):431-445.
3. Leape Ⅱ. Error inmedicine[J]. JAMA, 1994, 272(23):1851-1857.
4. Dew JR. Using root cause analysis to make the patient care system safe[C]//Proceedings of the 56th Annual Quality Congress in Denver. Denver:Annual Quality Congress, 2002:651-655.
5. Eagle CJ, Davies JM, Reason J. Accident analysis of large-scale technological disasters applied to an anaesthetic complication[J]. Can J Anaesth, 1992, 39(2):118-122.
6. Dixon JF, Wielgosz C, Pires ML. Description and outcomes of acustom web-based patient occurence reporting system developedfor baylor university medical center and other system entities[J]. Proc (Bayl Univ Med Cent), 2002, 15(2):199-202.
7. 陳梅花, 黃寶珠, 李敏紅, 等. 護生靜脈輸液的細節管理[J]. 護理學報, 2012, 19(2):29-31.
8. 梁麗云, 周望梅. 門診靜脈輸液患者配合實習護生操作意愿調查分析[J]. 護理學報, 2012, 19(8):32-35.
9. 吳慶錕. 根本原因分析法在護患糾紛中的應用[J]. 中國當代醫藥, 2012, 19(2):140-141.
10. 韓光曙. 醫院的安全文化與醫療安全[J]. 中華醫院管理雜志, 2004, 20(3):129-131.
11. Notan TW. System changes to improve patient safety[J]. BMJ, 2000, 320(7):771-773.
12. 王玲, 張艷. 護士在無責呈報制度下主動呈報不良事件的現狀分析及對策[J]. 護理管理雜志, 2009, 9(7):46-47, 56.
13. 鄭華蓉, 黃祥智. 實施免責法護理缺陷上報機制打造護理安全文化[J]. 護理學報, 2012, 19(7):36-38.
14. 林玉丹, 李麗香, 沈秋鳳, 等. 根本原因分析法在成批燒傷病人早期救治質量控制中的應用[J]. 護理研究, 2013, 27(20):2158-2159.
15. 周萍, 魏群. 根本原因分析法在社區血脂異常居民健康管理中的應用[J]. 全科護理, 2014, 12(11):970-971.

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West China Medical Journal

Efficacy of Root Cause Analysis on the Management of Adverse Nursing Events in the Infusion Room of the Department of Pediatrics

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