- 期刊
- OpenAccess
Root Cause Analysis Regarding the Quality Management of Intradialytic Hypocalcemia Due to Negligent Use of a Calcium-Free Dialysate
摘要
BACKGROUD: The purpose of patient safety is to direct all efforts towards preventing harm, while reducing the risk of any unnecessary injury to a patient during the process of maintaining their healthcare. Today, intradialytic hypocalcemia is uncommon in modern clinical practice. However, negligent use of a calcium-free dialysate developed as a threat even after passing through many-layered security detections, along with the detecting machine line of defense in our hospital. METHODS: Because it is both a rare occurrence and life-threatening as related to systemic medical error, our quality management team has applied a fishbone diagram to seek the possible causes of this event. Brainstorming was done according to the ＂P＂ categories of person, process, policies, provider, and plan. RESULTS: These 5 categories were then grouped to analyze the root cause before the team subsequently made an effort to find the proper feasible intervention and action plans according to the gaps and contributing factors of each category. This step-by-step guide provided a method to quickly improve the quality management and increase financial support for the hospital. CONCLUSION: In conclusion, clear policies, organizational leadership capacity, data to drive safety improvements, skilled healthcare professionals and the effective involvement of patients in our daily practice, are all necessary in order to ensure sustainable and significant improvements in the safety of healthcare.
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