应用根原因分析法分析1例造影剂导致PICC导管堵管的原因。通过事件调查、直接原因分析，确认根原因是PICC维护宣教流程不合理、增强CT检查流程不合理、对医护人员缺乏导管维护知识的培训。针对原因制定并执行设计健康教育检核表、制定增强CT检查流程、对医护人员进行培训等改进措施以避免类似事件的发生，保证PICC的正确使用与维护。%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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