1例先天性心脏病术后患儿因怀抱致低温烫伤事件的根因分析
Root Cause Analysis of a Child with Embrace Hypothermia Scald after Congenital Heart Disease Operation
张茜 1王艳娇 1王诗瑜 1邢海英 1李庆印1
作者信息
- 1. 中国医学科学院阜外医院 北京 100037
- 折叠
摘要
目的 探讨RCA2 在儿科重症监护病房怀抱患儿致低温烫伤事件中的应用效果.方法 成立RCA2 团队,对1例先天性心脏病术后患儿因怀抱护理造成低温烫伤事件进行根本原因分析,制订改进方案并落实.结果 规范了怀抱患儿操作标准化流程与评分标准,降低了术后患儿怀抱风险.结论 RCA2 可有效避免护理不良事件发生,保证医疗护理质量安全.
Abstract
Objective To investigate the application effect of Root Cause Analyses and Actions(RCA2)in em-braced child with hypothermia scald in pediatric intensive care unit.Methods A RCA2 team was established to analyze the root causes of a case of hypothermia scald caused by embrace nursing in a child with congenital heart disease after surgery,and to formulate improvement plans and implement them.Results The standardized procedures and scoring criteria of the children with embrace nursing were standardized,and the risk of embraced children after surgery was re-duced.Conclusion RCA2 can effectively avoid the occurrence of adverse nursing events and ensure the quality and safety of medical care.
关键词
RCA2/儿科重症监护病房/婴儿/怀抱护理/患者安全Key words
Root Cause Analyses and Actions/Pediatric Intensive Care Unit/Infant/Embrace Nursing/Patient Safety引用本文复制引用
出版年
2024
NETL
NSTL
万方数据