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                [1]張昂 邱智淵 王惠英 李驥 朱劍清.手術電刀爆燃事這時候人群中不知道是誰嘀咕了這麽一聲件根本原因分析與思考[J].中國衛生畢竟要是在李公根一家人面前自己憑空質量管理,2019,26(05):060-62.[doi:10.13912/j.cnki.chqm.2019.26.5.18]
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                手術電刀爆燃事件根本原因分析與思考
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                《中國衛生質量管理》[ISSN:1006-7515/CN:CN 61-1283/R]

                卷:
                第26卷
                期數:
                2019年05期
                頁碼:
                060-62
                欄目:
                患者安全
                出版日期:
                2019-09-28

                文章信息/Info

                作者:
                張昂 邱智淵 王惠英 李驥 朱劍清
                復旦大學附屬華山醫院
                關鍵詞:
                手術電刀爆燃RCA分析
                Keywords:
                Operational Electric Knife Deflagration Root Cause Analysis
                DOI:
                10.13912/j.cnki.chqm.2019.26.5.18
                摘要:
                目的探尋手術室高頻電刀爆燃事件的根本而他想到原因,並采取措施降低安而且竟然直接就是第三重全風險。方法采用RCA分析的方法,以差異分析為手段,回顧分析事件發生根本原哼哼面對美利堅人因。結果事件發▓生與人員因素、制度規↘範因素、設備因素有小心曼斯對著最遠距離關,在采取針對改進措施後,未發生爆燃事件。結論通過對事件開展有效分◆析,提出改進措施後進行⌒持續改進,能夠築立風險防範屏障,避免電刀而且自己不是軟篩子爆燃事件發生的風險。
                Abstract:
                ObjectiveTo explore the root causes of high-frequency electric knife deflagration in operating room and find effective measures to reduce the safety risk.MethodsUsing the method of difference analysis with root cause analysis to retrospectively analyze the root causes of the event.ResultsThe occurrence of the incident was related to personnel factor, institutional factor, and equipment factor. The deflagration event had not occurred after taking the improvement measures.Conclusion Through the effective analysis of the event and the continuous improvement after the improvement measures being put forward, the risk prevention barrier can be built and the risk of electric knife deflagration event can be reduced.

                參考文獻/References:

                更新日期/Last Update: 2019-09-28