RCA quality improvement practices in the administration of promet-hazine serious error
- VernacularTitle:RCA品质改善手法在异丙嗪严重给药错误中的应用
- Author:
Xuelian ZHANG
1
;
Ying HE
;
Caimei ZHANG
;
Xin XU
Author Information
1. 宁波市第四医院质控部
- Keywords:
Quality improvement;
Medication errors;
Promethazine
- From:
China Modern Doctor
2014;(24):119-122
- CountryChina
- Language:Chinese
-
Abstract:
Objective To offer reference that the hospital governors use RCA quality improvement method. Methods Carries on the case analysis according to the case using RCA methods of reality, such as promethazine special to the wrong medicine drug approaches pathways leading to patient consciousness change, put forward the improvement pro-posal for quality improvement. Results During the period from June 2012 to January 2014 , the hospital did not happen because the drugs special route of administration way wrong phenomenon. Conclusion Application of RCA techniques can help us find the system reasons for the incident, and then analyze the reasons, to take practical action to improve the corresponding. And share the case method, put an end to these events.
