麻醉安全与质控2025，Vol.7Issue(3)：227-232,6.DOI:10.3969/j.issn.2096-2681.2025.03.009
根本原因分析法在防控儿童静脉诱导后上呼吸道梗阻的应用效果
Effect of root cause analysis on preventing and controlling upper airway obstruc-tion following the induction of intravenous anesthesia in children
摘要
Abstract
Objective To examine the efficacy of root cause analysis(RCA)in averting and managing adverse events associated with upper airway obstruction during the intravenous induction phase in pediatric transport.Methods The RCA team was formed to trace the event and collect relevant materials using time series analysis.Proximate causes were identified through fishbone diagram analysis,followed by barrier analysis and action plan development.Continuous improvement was achieved through implementation and long-term monitoring.Simultaneously,the identification rates of high-risk pediatric patients and the incidence rates of malignant upper respiratory tract obstruction events between the same periods in 2023 and 2024 were retrospectively analyzed and compared.Results After improve-ment interventions,the risk prediction rate for upper airway obstruction significantly increased from 17.74％to 97.50％.Concurrently,the incidence rate of severe upper airway obstruction has decreased from 0.70％to 0.00％.Conclusion The application of RCA enables more clear and rapid identification of systemic defects in pediatric intravenous induction and transportation processes.Targeted improve-ment measures effectively avoid anesthesia risks and ensure patient safety.关键词
儿童/上呼吸道梗阻/静脉诱导/根本原因分析法Key words
children/upper airway obstruction/intravenous induction/root cause analysis引用本文复制引用
苏丹晨,陈祥楠,肖婷,邓恋,黎昆伟..根本原因分析法在防控儿童静脉诱导后上呼吸道梗阻的应用效果[J].麻醉安全与质控,2025,7(3):227-232,6.基金项目
广东省医学科学技术研究基金项目(A2024778) （A2024778）
广东省中医药局科研项目(20232009) （20232009）
