目的：：通过对非计划性拔除气管插管事件的回顾性分析，探讨降低此类事件发生的应对措施。方法：组成根本原因分析( RCA)小组，对2010年1月~2014年3月共14例ICU患者发生非计划性拔除气管插管的事件进行RCA分析，找到近端原因和根本原因。结果：系统原因是ICU非计划性拔除气管插管的根本原因。结论：改善约束材料，增加医护沟通，强化培训教育，实行预警教育，可防范ICU非计划性拔除气管插管的发生。%Objective:Patients with unplanned extubation in the ICU were analysed retrospectively to explore the mesures to prevent occurrences of the such incidents. Methods:A total of 14 patients in ICU with unexpected extubation events from January 2010 to March 2014,were analysed by the root cause analy-sis ( RCA) group to find the basic reason of the events. Results:The system fctors were the fundamental cause of the unplanned extubation in ICU patients. Conclusion:The use of appropriate binding materials,strengthen the medical communication,improve training and education and implementation of early warning education,can prevent occurrence of unplanned extubation in ICU.
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