根因分析法对1 例PICC 导管接头滑脱移位至心脏的分析及改进

王田芳，赵芳芳

（西安市中心医院消化科，陕西 西安，710003）

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摘要：

目的 应用根因分析法（RCA）分析1 例PICC 导管接头滑脱移位至心脏的原因，并提出整改措施。方法 运用根因分析 法分析1 例治疗间歇期出现PICC 导管接头滑脱并移位至心脏的原因。结果该患者经介入治疗，取出导管，1 周后出院。针对 原因，进一步提出整改措施，后面无此类事件发生。结论 肿瘤患者行PICC 置管化学治疗中，治疗间歇期导管的维护及并发 症的预防对PICC 置管患者至关重要，需要予以密切关注，避免不良事件发生。

关键词：PICC 导管；脱落；心脏；介入；根因分析（RCA）

中图分类号：R473文献标志码：A文章编号：2096-1413(2018)02-0086-02

Root cause analysis and improvement of 1 case of PICC catheter adapter slippage to the heart
WANG Tian-fang, ZHAO Fang-fang
(Gestroenterology Department, Xi``an Central Hospital, Xi``an 710003, China)

ABSTRACT: Objective To analyze the causes of 1 case of PICC catheter adapter slippage to the heart by root cause analysis (RCA) and put forward some corrective measures. Methods RCA was used to analyze the causes of a case of slippage of PICC catheter adapter to the heart in the therapy interval. Results The patient was given intervention treatment, removed the catheter and released from the hospital a week later. Then corrective measures were put forward according to the causes，no such incidents occurred. Conclusion For tumor patients with PICC catheter during chemical treatment, in the therapy intervals, maintenance of catheter and prevention of complications are major things, which need to be given more attention to avoid incidence of adverse events.
KEYWORDS: PICC catheter; slippage; heart; intervention; root cause analysis (RCA)

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