Root Cause Analysis on PICC Tube Plugging Caused by Contrast Medium
Author(s): DONG Ming-fen, LIN Ai-bao, HAN Yan-ping, SHAO Jing, GONG Yin-ya
Pages: 26-28
Year: 2015 Issue: 2
Journal: Hospital Management Forum
Keyword: Root cause analysis; Contrast medium; Tube plugging;
Abstract: Analyzed the causes of PICC tube plugging caused by contrast medium in one case with root cause analysis method. After case investigation and direct cause analysis, the root cause was identified as the irrational education process of PICC maintenance and irrational examination process of enhanced CT as well as the lack of training on medical workers in terms of tube maintenance. Based on these problems, made implemented health education checklist, improved the examination process of enhanced CT and carried out trainings on medical workers to avoid the reoccurrence of similar incident and ensure the correct use and maintenance of PICC.
Pages: 26-28
Year: 2015 Issue: 2
Journal: Hospital Management Forum
Keyword: Root cause analysis; Contrast medium; Tube plugging;
Abstract: Analyzed the causes of PICC tube plugging caused by contrast medium in one case with root cause analysis method. After case investigation and direct cause analysis, the root cause was identified as the irrational education process of PICC maintenance and irrational examination process of enhanced CT as well as the lack of training on medical workers in terms of tube maintenance. Based on these problems, made implemented health education checklist, improved the examination process of enhanced CT and carried out trainings on medical workers to avoid the reoccurrence of similar incident and ensure the correct use and maintenance of PICC.
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