Application of root cause analysis on the Swiss cheese model in the psychiatric nursing adverse events

Abstract

Objective To study the clinical methods and effects of root cause analysis on the application of the Swiss cheese model in the psychiatric nursing adverse events. Methods Safety management groups were established to train nurses, use Swiss cheese model to analysis the root cause, formulate the corrective measures. The annual rates of incidence and reporting rate of adverse events were compared. Results One year after the root cause analysis on the application of the Swiss cheese model, the annual number of patients increased from 3 420 to 3 730, the cases of nursing adverse events reduced from 141 to 120, and the rate of nursing adverse events dropped from 4.12 percents to 3.21 percents (χ2=4.16, P<0.05). The reporting cases of nursing adverse events increased from 65 to 102, and the reporting rate of nursing adverse events enhanced from 46.10 percents to 85.00 percents (χ2=42.57, P<0.01). Conclusions The use of root cause analysis on the application of the Swiss cheese model is the effective management model to analyze the nursing adverse events and to improve the nursing safety. Key words: Swiss cheese model; Root cause analyses; Adverse event