335起护理不良事件分析及对策

Analysis of the nursing adverse events based on 335 cases from the reporting system

目的通过分析不良事件发生的原因及特点,探讨如何避免不良事件的发生,为提高患者安全管理,制订相应防范措施减少不良事件提供依据。方法回顾某三级甲等综合医院2008年度护理系统上报的335起不良事件,对不良事件分类、发生原因、时间特点及护患比例进行研究。结果①护理不良事件前三位分别是管路滑脱、压疮、跌倒。②主要原因分别是评估不足和沟通不良。③护士资历与不良事件的发生有关。④资历较低的护士在评估及沟通方面存在显著不足。⑤一周之内以周三、周四为不良事件发生的高峰,而在一天之内,以8:00、15:00和22:00为不良事件发生的三大高峰。结论医院要从组织系统上改善人员配置并建立组织安全文化,对护理人员进行相关培训,提高护士整体的风险意识水平和综合素质是降低不良事件发生率的根本途径。科室改革护理人员的排班模式,按照患者的需求进行弹性排班是降低不良事件发生率的有效途径。

Objective To analyze the causes and feature of nursing adverse events in order to explore the strategies to avoid adverse events and enhance patient safety management. Methods A total of 335 cases of nursing adverse events reported in 2008 in a III-A hospital were retrospectively analyzed,including the categorization,causes,time distribution,and nurse-patient ratio. Results The top three kinds of nursing adverse events were tube emersion（n=185）,pressure sores（n=63）, and falls （n=33）. The main causes were inadequate assessment （n=86） and ineffective communication （n=73）. Most adverse events happened on junior nurses who had difficulties in patients assessment and communication.More nursing adverse events oeeured on Wednesday,Thursday,and weekends during a week,at 8am,3pm,and 10pm during a day. Conclusion The fundamental way of reducing the incidence of adverse events is to improve staff arrangement,build up a safety culture,strengthen nurse training to enhance their risk awareness and general quality. Moreover,it would be effective to reform the scheduling model based on patients needs.