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目的寻找造成非计划性拔管的根本原因,并依靠系统干预采取有效手段达到改善的目的。方法基于信息系统、采用根本原因分析法对2012年-2013年193例非计划性拔管行为特征进行回顾性分析,于2014年-2015年提出并实施基于多学科的、系统性的改善策略,对比实施前后非计划性拔管发生情况。结果实施前后全院非计划性拔管发生率由2.24‰下降至0.85‰,X~2=57.235,P<0.05,有统计学差异。因团队合作缺陷,如拔管时机、镇静等造成的非计划性拔管下降,重新置管率由56.95%上升至71.60%,X~2=5.134,P<0.05,有统计学差异。结论基于RCA的原因挖掘和系统干预手段有效解决了某院非计划性拔管发生率居高不下的患者安全问题,并推动了以“患者为中心”的团队合作和基于证据的作业流程制定方法。
Objective To find out the root causes of unplanned extubation and rely on system intervention to take effective measures to achieve the purpose of improvement. Methods Based on the information system, 193 cases of unplanned extubation traits from 2012 to 2013 were retrospectively analyzed by root cause analysis. A multidisciplinary and systematic improvement strategy was proposed and implemented from 2014 to 2015, Contrast before and after the implementation of unplanned extubation occurred. Results Before and after the implementation of the whole hospital unplanned extubation rate decreased from 2.24 ‰ to 0.85 ‰, X ~ 2 = 57.235, P <0.05, with statistical differences. Due to the lack of teamwork, such as the timing of extubation, sedation and other unplanned extubation decreased, the re-catheterization rate increased from 56.95% to 71.60%, X ~ 2 = 5.134, P <0.05, with statistical differences. Conclusion The reasoning and system intervention based on RCA can effectively solve the problem of patient safety in unplanned extubation in a hospital and promote the teamwork and evidence-based workflow of “patient-centered” Develop methods.