One case of adverse event of insulin pump magnetization by MRI examination in the Department of Endocrinology was analyzed.According to the RCA procedure,the root causes of the occurrence of the event was analyzed from the aspects of incident time sequence,fish bone map,risk prevention and control measures,tracking and evaluation.The work process was optimized,and appropriate countermeasures was developed.Basically,the occurrence of such adverse event was completely eradicated,the safety awareness of employees was improved,and the patient satisfaction level was improved.%对内分泌科1例患者行MRI检查导致胰岛素泵磁化的不良事件进行分析,根据RCA步骤,从事件发生时间序列表、鱼骨图、防控对策实施、追踪评价等方面分析该事件发生的根本原因,优化工作流程,制定相应对策,基本杜绝了此类不良事件的发生,增强了员工的安全意识,提高了患者的满意度.
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