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目的 对新疆医科大学第五附属医院2例急诊输液患者身份识别错误事件进行深入剖析，以明确原因、提出改进措施，优化急诊输液流程，提升患者安全管理水平。方法 运用根本原因分析法（RCA），组建专业团队，调查事件经过，绘制鱼骨图，从人员、流程、管理、方法、环境等多个维度系统分析事件原因。结果 识别出导致身份识别错误的多方面原因，包括新护士经验不足、查对流程执行不严、交接班流程不完善、培训体系不健全、缺乏信息化辅助设备及环境嘈杂等因素。结论 基于分析结果，提出强化人员培训、优化流程管理、引入先进设备、改善环境及完善监督机制等一系列改进措施，为减少类似医疗差错、提升急诊科医疗质量提供参考。
Abstract：Objective An in-depth analysis was conducted on two cases of emergency infusion patient identification errors at the Fifth Affiliated Hospital of Xinjiang Medical University, aiming to clarify the causes, propose improvement measures, optimize the emergency infusion process, and enhance patient safety management Methods Using the root cause analysis(RCA) method, a professional team was established to investigate the incident process, draw a fishbone diagram, and systematically analyze the causes from multiple dimensions including personnel, process, management, methods, and environment. Results Multiple factors contributing to the identification errors were identified, including insufficient experience of new nurses, inadequate implementation of verification procedures, imperfect shift handover processes, incomplete training systems, lack of information-assisted equipment, and a noisy environment. Conclusion Based on the analysis results, a series of improvement measures were proposed, including strengthening personnel training, optimizing process management, introducing advanced equipment, improving the environment, and perfecting supervision mechanisms, providing a reference for reducing similar medical errors and improving the quality of emergency care.
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基本信息:
DOI：10.20256/j.cnki.zgdxbl.20251217.012
中图分类号:R197.323
引用信息:
[1]王媛,张峪峪,李付儒.2例急诊输液患者身份识别错误事件的根因分析及心得体会[J].中国典型病例大全,2026,20(01):41-47.DOI:10.20256/j.cnki.zgdxbl.20251217.012.
2025-03-21
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2025-04-10
2025
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2025-12-17
2025-12-17
2025-12-17