术后患者转运交接不良事件根因分析与改进

对1例术后患者转运交接不良事件展开根因分析，通过原因挖掘，从加强术前评估准备、案例反省和培训学习、转运全流程规范运行、构建术后患者院内转运交接评估监测规范等方面加以改进。构建了术后患者转运交接管理规范，保障了患者安全。

Root Cause Analysis and Improvement of Adverse Events of Postoperative Transport and Handover

The root cause analysis of the transport and handover adverse events of a postoperative patient was analyzed.Through the exploration of the causes,the improvement was made in the aspects of strengthening preoperative assessment preparation,case reflection,training and learning,standardized operation of the whole process of transport,and establishment of the standards for the assessment and monitoring of the transport and handover in the hospital for postoperative patients.The management standard of postoperative patient transfer and handover was established to ensure the safety of patients.