目的 探讨根本原因分析法在术中压疮管理中的应用。方法 选取2014-11至2015-10某三甲医院行全麻手术的患者为对照组,2015-11至2016-10实施根本原因分析法后的全麻手术患者为观察组,对术中压疮的数据进行比较。结果 观察组术中压疮发生41例,发生率为0.27%;对照组术中压疮发生69例,发生率0.40%,观察组压疮发生率低于对照组(χ2=6.84,P＜0.01)。观察组高危患者86例中,发生压疮26例,发生率30.23%;对照组72例高危患者中,发生压疮38例,压疮发生率52.80%,观察组高危患者中压疮发生率低于对照组(χ2=14.45,P＜0.01)。观察组压疮患者中,Ⅰ期32例(78.05%),Ⅱ期9例(21.95%),无一例深部组织损伤;对照组压疮患者中,Ⅰ期48例(69.56%),Ⅱ期18例(26.09%),深部组织损伤3例;两组压疮类型分布比较,差异有统计学意义(Z=-2.098,P=0.036)。结论 根本原因分析法是一种系统的处理护理不良事件的科学方法,有利于降低护理不良事件发生率,提高护理质量,值得在临床工作中推广应用。
Abstract
Objective To explore the applicability of root cause analysis (RCA) to the prevention of intraoperative pressure sores.Methods Patients who had received operations under general anesthesia between November 2014 and October 2015 were selected as the control group while those between November 2015 and October 2016 after the application of RCA were chosen as the observation group. In this research, the incidence of intraoperative sores in the two groups was compared, and the efficiency of RCA in the prevention of intraoperative pressure sores was evaluated.Results The incidence of intraoperative pressure sores in the observation group and control group was 0.27% (41 cases) and 0.40% (69 cases), respectively (χ2=6.84,P＜0.01).The incidence of intraoperative pressure sores in high-risk patients was 30.23% (26/86) in the observation group, but was 52.80% (38/72) (χ2=14.45,P＜0.01) in the control group. The percentage of stageⅠsores, stage Ⅱ sores, and deep tissue injury in intraoperative pressure sores in the observation group was 78.05%, 21.95% and 0%, respectively, compared with 69.56%, 26.09% and 4.35% respectively in the control group. The difference between the two groups in stage distributions was significant (Z=-2.098,P=0.036).Conclusions Root cause analysis is an efficient method for preventing the occurrence of intraoperative pressure sores and is worthy of wide application.
关键词
根本原因分析法 /
术中压疮 /
预防
Key words
root cause analysis /
operation pressure sores /
prevention
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