摘要
目的:运用根本原因分析(RCA)法对患者影像归档及传输系统(PACS)图像传输错误的不良事件进行原因分析。方法:成立RCA小组对l例患者PACS图像传输错误事件进行调查,通过头脑风暴和鱼骨图方式,采用五问法查清影像图片错误不良事件的根本原因,制定有效的改进措施,控制此类事件再次发生。结果:经RCA法判定,l例患者PACS图像传输错误原因是甲乙患者名字同音。通过制定影像图片修改制度,完善住院患者影像检查流程,升级计算机断层扫描(CT)影像设备系统,加强人员培训等改进措施,有效减少了CT检查环节中错误的发生。RCA小组从2020年1月跟踪至2021年4月,影像图片无一发生错误,临床未再发生错误诊断事件。结论:运用RCA法分析医疗不良事件发生的根本原因,制定有效的改进措施,能有效防止类似事件再次发生。
Objective:To analyze the cause of adverse event of a patient with picture archiving and communication system(PACS)image transmission error by using root cause analysis.Methods:A root cause analysis(RCA)team was set up to investigate and restore the incident,the root cause of image picture error adverse event was found out through brainstorming and fishbone diagram by using five-question method,and effective improvement measures were formulated.Results:Image picture revision system was Formulated,image examination procedures for inpatients was improved,computed tomography(CT)image equipment system was upgraded,personnel training was strengthen and other improvement measures were taken to effectively reduce occurrence of errors in CT examination links.The RCA team followed up from January 2020 to April 2021,there was no error in imaging pictures,and no clinical misdiagnosis occurred.Conclusion:The application of RCA method to analyze the root causes of adverse medical events and to formulate effective improvement measures can effectively prevent similar incidents from happening.
作者
黄鹂
袁达
薛晓伟
彭华
HUANG Li;YUAN Da;XUE Xiao-wei(Department of Medical Services,Peking Union Medical College Hospital,Beijing 100730,China)
出处
《中国医学装备》
2022年第4期171-174,共4页
China Medical Equipment
