Suprani Riccarda, Pellegrini Rosalba, Vitullo Marialina, Fabbri Tulliio, Cimmati Marial Giulia
Funzione Aziendale Gestione del Rischio - AUSL Ravenna.
Prof Inferm. 2011 Jul-Sep;64(3):131-6.
Creation of the Root Cause Analysis (RCA) represents a phase of clinical risk management and is the instrument chosen for reactive analysis of adverse events. It is important to consider RCA in the context of the entire clinical risk management process and to understand the interrelationships with the previous and subsequent phases, in order to identify the necessary input and the expected output of such activity. In this study the input consisted of the adverse event which occurred after a health worker had been exposed to a biological risk and the "source patient sample" could not be found. The hospital and nursing authorities analyzed the event to understand its dynamics and causes. The results, or output, obtained indicate the steps necessary to go on to the next phase, namely treatment of the risk and the need for systemic measures: improvement of communication , revision of hospital procedures for managing blood samples and modification of the laboratory computer programs.
根本原因分析（RCA）的创建是临床风险管理的一个阶段，是用于对不良事件进行反应性分析所选用的工具。在整个临床风险管理过程的背景下考虑RCA，并理解其与前后阶段的相互关系非常重要，以便确定此类活动所需的输入和预期输出。在本研究中，输入包括一名医护人员接触生物风险后发生不良事件且找不到“源患者样本”的情况。医院和护理部门对该事件进行了分析，以了解其动态和原因。所获得的结果或输出表明进入下一阶段所需的步骤，即风险处理以及采取系统性措施的必要性：改进沟通、修订医院血液样本管理程序以及修改实验室计算机程序。
