RCA分析法在一例动力工具配件遗失中的应用

Application of Root Cause Analysis in a Case of Power Tool Accessory Loss

摘要: 目的：探讨根本原因分析法(RCA)，在消毒供应中心器械遗失中的应用效果。方法：全面收集相关资料，回顾性分析动力工具配件遗失的管理情况，从人、机、料、法、环、测(5M1E)六大维度，通过“鱼骨图”分析事件近端原因，明确根本原因，制定针对性整改对策，防范器械遗失事件的再发生。结果：通过制定并落实针对性整改措施，完善了消毒供应中心特殊器械管理的制度流程，提升了医护人员的专业能力与风险意识，健全了质量监测与追溯体系，实现了特殊器械管理的标准化、精细化。结论：采用RCA分析法能够有效挖掘消毒供应中心器械管理中的潜在问题，制定整改措施，可有效规避同类不良事件复发，为医疗安全保障提供切实支撑。

Abstract: Objective: To explore the application effect of Root Cause Analysis (RCA) in instrument loss in Central Sterile Supply Department (CSSD). Methods Relevant data were comprehensively collected, and the management of power tool accessory loss was retrospectively analyzed. From the six dimensions of man, machine, material, method, environment, and measurement (5M1E), the proximal causes of the incident were analyzed through a fishbone diagram, the root causes were clarified, targeted rectification measures were formulated, and the recurrence of instrument loss incidents was prevented. Results: Through the formulation and implementation of targeted rectification measures, the system and process of special instrument management in CSSD were improved, the professional competence and risk awareness of medical staff were enhanced, the quality monitoring and traceability system was improved, and the standardized and refined management of special instruments was realized. Conclusion: The application of RCA can effectively explore potential problems in instrument management in CSSD, formulate rectification measures, effectively prevent the recurrence of similar adverse events, and provide solid support for medical safety assurance.