关键词: font-size:medium, ">踪近差错事件；根本原因分析（RCA）；眼科；手术安全核查

Abstract: Objective： To find out the influence of non-human factors on the near error event of eye error trace in ophthalmic surgery by using quality management tools. Methods：Retrospective analysis was made on the data of medical/nursing related safety events in the ophthalmic operation department of a three A hospital in Zhengzhou in 2018. Root cause analysis (RCA) was used to analyze the proximal cause of a typical case. The root cause analysis was conducted by investigating the current situation of ophthalmic surgery safety verification,then take measures to provide solutions, and evaluate the effect of rectification after half a year of implementation. Results： There were 3 similar near miss events in total. The RCA specific steps were used to form a team to complete the root cause analysis， relevant interventions were taken. The implementation rate of operation safety verification increased from 65% to 96%， and no similar near miss events occurred by the end of December 2019. Conclusion：Scientific quality management tool RCA can effectively reduce the occurrence of similar ocular errors.

Key words: font-size:medium, ">Tracking near error events； Root cause analysis (RCA)； Ophthalmology； Operation safety verification