1例血小板输错事件的根本原因分析
Chinese Health Quality Management（2016）
Abstract
针对1例血小板输错事件,成立RCA团队,完成事件描述表,应用鱼骨图寻找近端原因,采用五问法剖析根本原因,制定针对性改进对策并落实,为临床安全用血提供保障.
MoreKey words
Root Cause Analysis,Clinical Blood Use,Closed-Loop Management
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