A case's root cause analysis of osteofascial compartment syndrome induced by radial artery puncture and its defensive strategy

Feng-Ying Kang , Yang Yang , Yu-Ping Tong , Ya-Li Hu , Ning-Ning Xue
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引用次数: 0

Abstract

Objective

The objective of this study was to reduce or avoid the occurrence of the cases of osteofascial compartment syndrome induced by a radial artery puncture for arterial blood gas analysis.

Methods

We analyzed an adverse event using cheese model analysis, “fish bone” analysis, root cause analysis, and other methods.

Results

There are three root causes leading to an adverse event: operation technique, assessment of the disease, and informing patient families. However, there are many reasons to promote the occurrence and development of the event.

Conclusions

We should analyze and manage the adverse events in patients from the point of view of a system. Developing the measures of a system defense can enhance patient safety and create a good safety culture.

桡动脉穿刺致骨筋膜室综合征1例根本原因分析及防御策略
目的减少或避免桡动脉穿刺动脉血气分析所致骨筋膜室综合征的发生。方法采用奶酪模型分析、“鱼骨”分析、根本原因分析等方法对一起不良事件进行分析。结果导致不良事件发生的根本原因有三个:手术技术、病情评估和告知患者家属。然而,推动事件发生和发展的原因是多方面的。结论应从系统的角度分析和处理患者的不良事件。制定系统防御措施可以增强患者安全,营造良好的安全文化。
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