چاپ صفحه |  صفحه نخست سامانه |  نویسندگان |  اطلاعات تفضیلی |  دانلود مقاله | دانشگاه علوم پزشکی تبریز |
| نویسنده | نفر چندم مقاله |
|---|---|
| منصور رضائی | اول |
| هانیه اصغریان | دوم |
| آسیه قاسم پور نجاتی | سوم |
| عنوان | متن |
|---|---|
| خلاصه مقاله | Introduction: Root cause analysis (RCA) is a systematic process to study the causes of adverse events. Adverse events are common due to individual errors and system weaknesses in hospitals. The purpose of this study was to examine RCA reports to determine the frequency and causes of asphyxia in infants at Taleghani Hospital. Methods: This study was a retrospective descriptive study in which all RCA reports related to asphyxia from 1396 to the end of the first six months of 1402 were reviewed and the frequency of occurrence and attributed causes were extracted. Descriptive statistics were used to determine the frequency of factors responsible for the occurrence of each adverse event. Results: Of the 2680 staff- reported errors, 53 cases were never-event errors, of which most statistics related to moderate and severe neonatal asphyxia, 22 cases (41.50%). When these 22 cases were examined, the most important factors were attributed to causes related to service (59.09%) and factors related to training (31.81%). Regarding the causes related to service and training, ignoring guidelines, inadequate supervision, and lack of communication skills were among the most important factors for the occurrence of the asphyxia studied. Conclusion: In developed countries, the rate of asphyxia is 1 to 3 cases per 1000 live births, although the number of asphyxia cases (22 cases in 28571 live births during the study) was lower (0.07%) in this center. Because asphyxia is not expected to occur in the center, it is suggested that the EDU of the center develop coherent training protocols and communication guidelines, monitor the implementation of evidence-based intervention programs, and share RCA results among physicians, clinical staff and learners to learn from mistakes. |
| کلمات کلیدی | RCA, asphyxia, Medical error |
| نام فایل | تاریخ درج فایل | اندازه فایل | دانلود |
|---|---|---|---|
| photo11036093864.jpg | 1403/02/12 | 133307 | دانلود |
| photo11036093821.jpg | 1403/02/12 | 97742 | دانلود |
