阿合奇县人民医院257例护理不良事件原因分析及预防策略

Cause analysis and prevention strategies of 257 cases of care adverse events in People's Hospital of Akqi County

目的分析护理不良事件发生的原因,探讨防范对策,为基层医院不良事件的防范及护理安全管理提供依据。方法分析笔者所在医院2010年1月～2012年5月上报的257例护理不良事件,对不良事件的发生原因、特点及与护士资历、族别的关系进行归纳汇总,并分析讨论,探讨护理不良事件的预防策略。结果护理不良事件的发生主要与制度执行不力、工作流程不明确、工作规范不完善、仪器设备管理不力、护士资历偏低等因素有关。护理不良事件前3位分别是:伪造护理数据、病历书写缺陷、漏做治疗。不良事件发生几率:低年资护士高于高年资护士,少数民族护士高于汉族护士。资历较低的护士在评估、沟通及执行能力方面存在明显不足。少数民族护士在安全意识方面明显低于汉族护士。结论完善基层医院护理人力资源配置,改革护士排班模式,按照需求弹性排班是降低不良事件发生的有效途径。加强基层医院核心制度的落实,重视工作流程改进,加强低年资护士的考核培训,提高护士风险意识和综合素质是减少护理不良事发生的根本途径。

Objective To analyze the causes of nursing adverse events and explore preventive measures, which provides the basis for basic level prevention of hospital adverse events and nursing safety management. Methods The report of 257 cases of nursing adverse events were analyzed from January 2010 to May 2012 to summary adverse events on causes, characteristics ,the nurse qualification, the relations of race, and explore the nursing adverse events prevention strategy by analysis and discussion. Results Nursing adverse events occurred mainly with the weak implementation of the system, the not clear process of work, not perfect standards, poor management of instruments, low nurse qualifications. Nursing adverse events before three respectively were fake nursing data, defects in medical records writing and leakage to do treatments. The occurrent probability of adverse events of the low seniority nurses were higher than that of high qualification, nurses of ethnic minority were higher than that of Han. The nurses with low qualifications had significant deficiency in assessment, communication and executive ability. The nurses of minority were obviously lower than the nurses of Han in safety awareness. Conclusion It is effective to reduce the incidence of adverse events by improving the resource allocation of nurses in basic level hospital, reforming the nurse scheduling model and scheduling according to the demands. To reduce the happening of adverse events. It is basic way to strengthen the implementation of core system in basic-level hospitals, pay attention to the improvement of work process, strengthen the examination and training of junior nurses, and improve the risk consciousness and comprehensive quality of nurses.