运用SHEL模式分析精神科护理不良事件

The Application of SHEL Model in Analysis of the Nursing Adverse Events in the Psychiatric Department

目的探讨SHEL模式在分析护理不良事件发生原因中的作用。方法对2005—2006年发生的45起护理不良事件运用SHEL模式进行分类及原因分析,提出相应改进措施。结果与软件部分(soft),即护士业务素质和能力有关的占89%(40例),与硬件部分(hard),即护理工作场所有关的占62%(28例),与临床环境(environment)有关的占47%(21例),与当事人及他人(litigant)有关的占64%(29例)。在此基础上提出改进措施,2007—2008年共发生24起护理不良事件,与2005—2006年比较,差异有统计学意义(P<0.01)。结论应用SHEL模式分析及防范护理不良事件有积极意义,能显著减少护理不良事件的发生,促进护理安全。

Objective To explore application of SHEL model in analysis of the nursing adverse events in the psychiatric department. Methods 45 nursing adverse events in 2005 and 2006 were classified and analyzed under the SHEL model. The corresponding strategy was made to prevent nursing adverse events. Results For the 45 adverse events, 40 ones （89%） were related to the nurse＇s professional quality and ability, 28 （62%） to nursing locations, 21 （47%） to clinical environment and 29 （64%） to the litigant and other persons. After the manipulation of the corresponding strategy, there occurred only 24 adverse events during 2007-2008, which signif- icantly dropped compared to 2005-2006 （P〈0.01）. Conclusion The SHEL model is effeetive for analyzing and preventing the nurs- ing adverse events. It can be meaningful in reduction of nursing adverse events and promote nursing safety.