Najafpour Zhila, Jafary Mohamadreza, Saeedi Morteza, Jeddian Alireza, Adibi Hossein
Health care management, Department of Health Economics and Management, School of Public Health, Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran.
Shariati Hospital,Tehran University of Medical Sciences, Tehran, Iran.
J Diabetes Metab Disord. 2016 Jul 28;15:27. doi: 10.1186/s40200-016-0249-3. eCollection 2015.
One of the most important concerns of health care systems in the world is the patient safety issues. Root Cause Analysis is a systematic process for identifying root causes and contributory factors of problems or events. The objective of this study is to review RCA reports to determine the effect size of contributory factors on adverse events through an organizational perspective.
This study was conducted in a tertiary care teaching hospital in 2014. The process of root cause analysis was taken from National Patient Safety Agency framework. We calculated descriptive statistics to determine the frequency distribution of contributory factors on each adverse event.
Having the process of 16 adverse events reviewed, 38 care or service delivery problems were identified which showed that 317 contributory factors and underlying causes had led to these problems. Accordingly, the most important contributory factors included the following: Task factors (20 %), education and training factors (16 %), communication factors (14 %), and team and social factors (13 %).
RCA is an effective method of problem solving used for identifying the root causes of initial errors and finding ways to prevent the recurrences. In this study, lack of effective communication skills of nurses and other clinical staff when interacting with colleague and communicating with patients, failure to comply with health care provision standards, lack of adequate supervision on implementation of clinical guidelines and issues related to the organizational culture were the main determining factors which have been considered for implementing preventive measures with regard to the hospital specifications.
全球医疗保健系统最为关注的问题之一是患者安全问题。根本原因分析是一个用于识别问题或事件的根本原因及促成因素的系统过程。本研究的目的是通过组织视角回顾根本原因分析报告，以确定促成因素对不良事件的影响程度。
本研究于2014年在一家三级护理教学医院开展。根本原因分析过程采用了国家患者安全机构的框架。我们计算了描述性统计数据，以确定每个不良事件中促成因素的频率分布。
在对16起不良事件的过程进行审查后，识别出38个护理或服务提供问题，这表明317个促成因素和潜在原因导致了这些问题。因此，最重要的促成因素包括：任务因素（20%）、教育与培训因素（16%）、沟通因素（14%）以及团队与社会因素（13%）。
根本原因分析是一种有效的解决问题方法，用于识别初始错误的根本原因并找到预防复发的方法。在本研究中，护士和其他临床工作人员在与同事互动及与患者沟通时缺乏有效的沟通技巧、未遵守医疗保健提供标准、对临床指南实施缺乏充分监督以及与组织文化相关的问题是主要的决定因素，已考虑根据医院具体情况实施预防措施。
