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目的:通过调查分析我院近期8例新生儿脓疱疹医院感染的原因,找出并矫正在院感防控工作中存在的问题,避免新生儿脓疱疹医院感染的发生,保证患者安全。方法:采用根源分析法(RCA)对8例新生儿脓疱疹进行回顾性分析,找出根本原因,并采取有效防控新生儿脓疱疹的措施。结果:在确认近端因素后对患儿进行了随机病例对照研究(RCT),认为新生儿沐浴时工作人员操作不规范是造成本次新生儿脓疱疹医院感染的根本原因。结论:采用RCA实施联动措施能及时发现临床及护理工作中的疏漏环节及其根本原因,进而有针对性地采取一系列改进措施,能有效降低新生儿脓疱疹医院感染的发生率。
Objective: To investigate and analyze the causes of nosocomial infections in 8 cases of neonatal pustular herpes in our hospital recently, find out and correct the problems existing in the prevention and control of hospital sensation, avoid the occurrence of neonatal impetigo nosocomial infection, and ensure the safety of patients. METHODS: Eight cases of neonatal impetigo were retrospectively analyzed using root-cause analysis (RCA) to identify the underlying causes and to take effective measures to prevent and treat neonatal impetigo. RESULTS: A randomized case-control study (RCT) was conducted after confirming the proximal factors. It was considered that the non-standard operation of the newborns during bathing was the underlying cause of the neonatal impetigo nosocomial infection. Conclusion: The use of RCA to implement linkage measures can promptly identify the missing links and root causes in clinical and nursing work, and then adopt a series of targeted measures to improve the incidence of neonatal impetigo nosocomial infection.