利用根本原因分析（Root Cause Analysis，RCA）改善化療藥物外滲事件

Purpose: The aim of this article was to describe the use of root cause analysis (RCA) for identifying the possible causes of an adverse event involved vesicant extravasation injury from a central venous Port-A catheter, a rare reported, and provide attention & prevention.Methods: As a serious and sentinel event, an investigation team was established. Key participants were identified and an RCA was implemented systematically with a trained facilitator guiding each analysis step. Chronological narratives were tabulated in a timeline sheet. Why tree & Barrier analysis were used to determine the root factors of this event.Results: Three root causes of the extravasation event were identified, which included 1. Port-A needle was not qualify, 2. Nurse was not alert of the potential of extravasation of the patients first time receiving chemotherapy, 3. Reporting of adverse event was slow. Based on the analysis, we implemented action plan to ensure safety in administering chemotherapy. After the improvement measures, we have not had similar event recurred.Discussion: RCA is a useful tool to identify the causes of an adverse event. Subsequent measures can target the causes to prevent or reduce future occurrence of the event. However, implementing the desired changes can be a challenge in which the measure required negotiation of changes outside of our institution.