根本原因分析法在住院患者自带药品管理质量改进中的应用研究

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中图分类号：R197.323;R9 文献标识码：B

ResearchontheApplicationofRotCauseAnalysis inQualityImprovementofSelf一AdministeredMedicationManagementforHospi talizedPatients/WANGLi，XIAYan，TANGLeilei，etal.//ChineseHealth QualityManagement，2025，32（9）：5一40

Abstract Objective To explore the improvement effects of applying root cause analysis （RCA） to address adverse events related to the use of patients'self一administered medications during hospitalization.MethodsAn RCA team was established to reconstruct theevent timeline，identify issues，investigate proximal causes，determine root causes through fault treeanalysis，anddevelop and implementanaction plan for continuous improvement.ResultsAfter implementing the improvement actionplan for self一administered medications，the nursesmasteryrate of information on patients self-administered medications increased to 88.89% ， the accuracy rate of medical orders for self-administered medications improved to 87.67% ，the implementation rate of psychological assessments for patients rose to 91.67% = and the incidence of adverse events related to self-administered medications decreased to 1.85% .Statistically significant differences were observed when comparing these metrics before and after implementation （ P<0. 05 ）.Conclusion ApplyingRCA toanalyze adverse events related totheuseof self-administered medications among hospitalized patients enablestargeted quality improvement，ensuring medication safety for inpatients and enhancing thequalityof medication safety management.

Key words Root Cause Analysis；Hospitalized Patients；Self一Administered Medication；Medication Safety；Patient afetv

First-authorsaddress Nanjing Drum Tower Hospital，Nanjing，Jiangsu，2looo8，China

患者自带药品是指就诊期间，患者本人或家属从院外带人医疗机构，需要继续服用的药品[1]。（剩余8096字）