智能化护理风险防控系统的建立与应用

Establishment and application of the smart nursing risk management system

目的指导护士识别并预警护理风险,提供风险防控计划及措施的决策支持。方法建立智能化护理风险防控系统,经过文献检索、循证证据筛选、德尔菲专家咨询,筛选护理风险指标、确定护理风险的评估工具、制订评估指引及一系列针对不同风险及不同风险级别的防控措施,与电子病历整合,优化界面与功能。培训后在全院普通病区应用。护理部每季度审核各病区使用情况、统计不良事件发生率,并自行设计问卷进行满意度调查。结果全院普通病区应用率达100%,应用后压力性损伤发生率显著下降(P<0.05);护士对该系统的整体满意率为90.56%,对系统能够提高工作效率、保障患者安全、提供科学的决策支持的赞同率分别为85.66%、84.30%和89.66%。结论智能化护理风险防控系统能够增强护士对护理风险的预见性及风险管理意识,提高工作效率,降低护理不良事件发生率,保障患者安全。

Objective To guide clinical nurses identify and warn nursing risk, and to provide decision supports for risk prevention and control scheme. Methods A smart nursing risk management system(SNRMS) was established based on literature research, evidence screening and Delphi study, then nursing risk indicators were screened and assessment tools were selected, assessment guideline and prevention and control measures targeted for each risk factor were developed and added in the INRMS, which was then integrated with the medical record system, and its interface and function were optimized. Then the system was applied in all general wards of our hospital after medical staff training. Its application in each ward was audited by nursing department quarterly, the incidence of adverse events was calculated, and medical staff′s application satisfaction was investigated using self-designed questionnaire. Results The application rate of the SNRMS in general wards reached 100%, pressure injury decreased significantly after the application(P<0.05). Nurses′ total satisfaction to the system was 90.56%, and their approval rate on the system improving work efficiency, ensuring patient safety, providing scientific decision support was 85.66%, 84.30%, 89.66% respectively. Conclusion Application of the SNRMS can strength nurses′ nursing risk foreseebility and awareness of risk management, improve work efficiency, reduce incidence of nursing adverse events, and ensure patient safety.