Objective To explore the application effect of root cause analysis(RCA)in counting adverse events of surgical gauze.Methods The RCA team was established to trace the event process,and use a time series table to or-ganize data.After identifying the proximal cause,an improved causal tree was used to analyze the root causes.Through barrier analysis,the formulation and ultimately implementation of action plans,long-term monitoring of continuous improvement effects was carried out.Results After the improvement,the implementation rate of gauze into the bag,the inventory rate of natural cavity surgical items,the fixed-point placement rate of small gauze on the stage,and the non-stacking implementation rate of cleaning garbage bags increased significantly(P＜0.05).The baseline of pick-up time for the medical department(5 minutes)was provided,and a kind of counting equipment which can identify the con-sistency of gauze was developed.Conclusion The application of RCA in the analysis of adverse events of surgical gauze counting can more clearly identify the system defects in the gauze counting process in the operating room and make targeted improvements,so as to effectively avoid nursing risks and ensure patient safety.
Root Cause AnalysisOperating RoomInventory of GoodsAdverse EventsPatient Safety
NETL
NSTL
万方数据
