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目的:探讨根因分析法(RCA)在预防冠心病患者漏服药物中应用的效果。方法:运用根因分析法对2014年10月—2014年12月100例冠心病患者中12例漏服硝酸异山梨酯药物事件,进行近端原因、根本原因分析。制订完善的工作流程、合理的健康教育措施,提高患者对药物的知晓率。结果:2015年1月—2015年3月随访100例出院冠心病患者,漏服硝酸异山梨酯3例,漏服率由12%降至3%。结论:应用根因分析法确定根本原因,减少了冠心病患者的漏服药物率。
Objective: To investigate the effect of root cause analysis (RCA) on the prevention of missed medication in patients with coronary heart disease. Methods: Twelve cases of isosorbide dinitrate in 100 patients with coronary heart disease from October 2014 to December 2014 were analyzed by root-cause analysis. The causes of the proximal and the root causes were analyzed. Develop a sound workflow, reasonable health education measures to improve the patient’s awareness of drugs. Results: From January 2015 to March 2015, 100 patients with coronary heart disease were followed up. Three patients were given isosorbide dinitrate. The leakage rate dropped from 12% to 3%. Conclusion: Root cause analysis is used to determine the root cause and reduce the missed medication rate in patients with coronary heart disease.