Effect of root cause analysis on preventing and controlling upper airway obstruc-tion following the induction of intravenous anesthesia in children
SU Danchen
CHEN Xiangnan
XIAO Ting
DENG Lian
LI Kunwei
Abstract：Objective To examine the efficacy of root cause analysis(RCA)in averting and managing adverse events associated with upper airway obstruction during the intravenous induction phase in pediatric transport.Methods The RCA team was formed to trace the event and collect relevant materials using time series analysis.Proximate causes were identified through fishbone diagram analysis,followed by barrier analysis and action plan development.Continuous improvement was achieved through implementation and long-term monitoring.Simultaneously,the identification rates of high-risk pediatric patients and the incidence rates of malignant upper respiratory tract obstruction events between the same periods in 2023 and 2024 were retrospectively analyzed and compared.Results After improve-ment interventions,the risk prediction rate for upper airway obstruction significantly increased from 17.74％to 97.50％.Concurrently,the incidence rate of severe upper airway obstruction has decreased from 0.70％to 0.00％.Conclusion The application of RCA enables more clear and rapid identification of systemic defects in pediatric intravenous induction and transportation processes.Targeted improve-ment measures effectively avoid anesthesia risks and ensure patient safety.
Keywords：childrenupper airway obstructionintravenous inductionroot cause analysis
Publication Date：2025-06-15
Online Publishing Date：2025-08-15(First online date of this platform, not the publication date of the document)
Pages：6( 227-232 )