Application of root cause analysis tomedium pressure sore prevention
LIU Xiaoyan1, SUN Ling1, LI Juan2,LI Ying3,and ZHANG Wenjing4
.1.Surgical Operating Room, 2.Department of Neurosurgery, 3.Departmentment of Transplantation, 4.Department for High Fever,General Hospital of Chinese People’s Armed Police Force, Beijing 100039, China
Abstract：Objective To explore the applicability of root cause analysis (RCA) to the prevention of intraoperative pressure sores.Methods Patients who had received operations under general anesthesia between November 2014 and October 2015 were selected as the control group while those between November 2015 and October 2016 after the application of RCA were chosen as the observation group. In this research, the incidence of intraoperative sores in the two groups was compared, and the efficiency of RCA in the prevention of intraoperative pressure sores was evaluated.Results The incidence of intraoperative pressure sores in the observation group and control group was 0.27% (41 cases) and 0.40% (69 cases), respectively (χ2=6.84,P＜0.01).The incidence of intraoperative pressure sores in high-risk patients was 30.23% (26/86) in the observation group, but was 52.80% (38/72) (χ2=14.45,P＜0.01) in the control group. The percentage of stageⅠsores, stage Ⅱ sores, and deep tissue injury in intraoperative pressure sores in the observation group was 78.05%, 21.95% and 0%, respectively, compared with 69.56%, 26.09% and 4.35% respectively in the control group. The difference between the two groups in stage distributions was significant (Z=-2.098,P=0.036).Conclusions Root cause analysis is an efficient method for preventing the occurrence of intraoperative pressure sores and is worthy of wide application.
Vangilder C A, Amlung S, Harrson P, et al. Results of the 2008-2009 International Pressure Ulcer Prevalence TM Survey and a 3-year, acute care, unit specific analysis [J]. Ostomy Wound Manage, 2009, 55(11): 39-45.
[6]
Jenkins M L, O’Neal E. Pressure ulcer prevalence and incidence in acute care [J]. Adv Skin Wound Care, 2010, 23(12):556-559.
[7]
Hart S, Bergquist S, Gajewski B, et al. Reliability testing of the national database of nursing quality indicators pressure ulcer indicators[J]. J Nurs Care Qual,2006, 21(3): 256-265.
Neily J, Ogrinc G, Weeks W B. Reducing medication confusion in homebound patients: when the data do not conform to the initial hypothesis [J]. Jt Comm J Qual Saf, 2003, 29(4): 199-200.
2017, Vol. 28 
