根因分析法在颅脑手术后颅内感染控制中的应用
Application of root cause analysis method in control of intracranial infection after intracranial surgery
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摘要: 目的 了解根因分析法在颅脑手术颅内感染患者控制中的应用效果,为医院感染管理工具的应用提供参考。方法 调查2014年1-9月发生颅内感染患者的资料,使用根因分析法进行根本原因分析,制定并实施围术期无菌操作过程监控机制,实行手术器械集中清洗消毒,强化对医护人员培训等改进措施,于2014年11月-2015年7月评估改进效果,比较根因分析实施前、后神经外科显微器械清洗合格率、外科手术人员手术时无菌操作规范性、颅脑术后颅内感染发生率。结果 实施根因分析后,神经外科显微器械清洗合格率和外科手术人员术中无菌操作规范率较实施前明显增高,差异有统计学意义(P< 0.05);颅脑手术后颅内感染发生率在根因分析实施前、后分别为2.67%和0,两者差异有统计学意义(P<0.05)。结论 运用根因分析法可更加系统、直接地找到事件发生的根本原因,采取相应改进措施,从而有效降低颅脑手术后颅内感染发生率。Abstract: OBJECTIVE To explore the effect of root cause analysis method in the control of intracranial infection caused by intracranial surgery,so as to provide references for the application of hospital infection management tools.METHODS Data of patients with intracranial infection from Jan.to Sep.2014 were investigated and analyzed by root cause analysis method,and then some measures such as the monitoring mechanism of the operation process of the perioperative period,the cleaning and disinfection of the surgical instruments,and the strengthening of the training of the medical staff were taken.The improvement effects were evaluated in Nov.2014-Jul.2015,and the incidence of intracranial infection after intracranial surgery,the qualified rate of cleaning instruments and the standardization of the surgical aseptic operation of neurosurgery were compared before and after the implementation of root cause analysis method.RESULTS After the application of the root cause analysis method,the qualified rate of cleaning instruments and the standardization of the surgical aseptic operation were higher than before,and the difference was significant(P<0.05).The incidence of intracranial infection after intracranial surgery had reduced from 2.67%to 0,and the difference was significant(P<0.05).CONCLUSION The application of the root cause analysis method can find the root cause of the incident systematically and directly,and then taking the corresponding improvement measures can effectively reduce the incidence of intracranial infections after intracranial surgery.
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