麻醉安全与质控2024，Vol.6Issue(2)：89-92,4.DOI:10.3969/j.issn.2096-2681.2024.02.007
一例全身麻醉非眼科手术患者角膜擦伤的根本原因分析与改进
Root cause analysis and improvement of corneal abrasions in a case of non-ocular surgery patient under general anesthesia
邢雪燕 1王飞 1刘鑫雨 1刘筱璨 1郭晓慧 1严思益 1肖博 2苏博兴 2涂淑敏1
作者信息
- 1. 清华大学临床医学院,清华大学附属北京清华长庚医院麻醉科,北京 102218
- 2. 清华大学临床医学院,清华大学附属北京清华长庚医院泌尿外科,北京 102218
- 折叠
摘要
Abstract
The root cause of corneal abrasions in a case of non-ocular surgery patient under general anesthesia was analyzed.In order to present the whole process of root cause analysis(RCA)in this case,the five steps of RCA were as follows,problem definition and event description,identification of possible causes,analysis of root causes,formulation and implementation of improvements.The improvements were made in the following aspects,establishing supervision and assessment mechanism for ECG monitoring operation,strengthening the training of mask ventilation technique for nurse anesthetists,adding eye protection measures during mask ventilation and eye protection measures for special surgical position,which have achieved good results.This paper provides the ideas and methods of quality manage-ment for clinical supervisors,so as to better identify the problems in the management system and formulate targeted improvement plans and preventive measures.关键词
全身麻醉/非眼科手术/角膜擦伤/根本原因分析Key words
general anesthesia/non-ocular surgery/corneal abrasions/root cause analysis引用本文复制引用
邢雪燕,王飞,刘鑫雨,刘筱璨,郭晓慧,严思益,肖博,苏博兴,涂淑敏..一例全身麻醉非眼科手术患者角膜擦伤的根本原因分析与改进[J].麻醉安全与质控,2024,6(2):89-92,4.
