Root cause analysis and improvement of corneal abrasions in a case of non-ocular surgery patient under general anesthesia
XING Xueyan
WANG Fei
LIU Xinyu
LIU Xiaocan
GUO Xiaohui
YAN Siyi
XIAO Bo
SU Boxing
TU Shumin
Abstract：The root cause of corneal abrasions in a case of non-ocular surgery patient under general anesthesia was analyzed.In order to present the whole process of root cause analysis(RCA)in this case,the five steps of RCA were as follows,problem definition and event description,identification of possible causes,analysis of root causes,formulation and implementation of improvements.The improvements were made in the following aspects,establishing supervision and assessment mechanism for ECG monitoring operation,strengthening the training of mask ventilation technique for nurse anesthetists,adding eye protection measures during mask ventilation and eye protection measures for special surgical position,which have achieved good results.This paper provides the ideas and methods of quality manage-ment for clinical supervisors,so as to better identify the problems in the management system and formulate targeted improvement plans and preventive measures.
Keywords：general anesthesianon-ocular surgerycorneal abrasionsroot cause analysis
Publication Date：2024-04-15
Online Publishing Date：2025-08-15(First online date of this platform, not the publication date of the document)
Pages：4( 89-92 )