120例住院精神障碍患者护理不良事件原因分析及对策

Analysis of the nursing adverse events based on 120 mental disorder patients and countermeasure

目的通过分析3年间120例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。方法回顾厦门市精神卫生中心2009～2011年护理系统上报的120例不良事件，对不良事件分类、发生原因、时间特点、损伤程度等进行研究。结果①住院精神障碍患者发生的护理不良事件前三位分别是跌倒（45．8％）、外逃（15．8％）、自伤与伤人（11．7％）。②法律后果最严重的是患者的自杀、自伤及伤人、外逃。③日间发生的不良事件多于夜间。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，完善护理流程，定期对护理人员进行风险意识水平和综合素质培训，同时改革护理人员的排班模式，按照患者的需求进行弹性排班，做好患者的健康教育是有效减低精神科护理不良事件的根本途径。

Objective To analyze the causes and feature of nursing adverse events in order to make the strategies to avoid adverse events and enhance mental disorder patients safety management. Methods A total of 120 cases of nursing adverse events reported from 2009 to 2011 in Xiamen Mental Health Center were retrospectively analyzed, including the categorization, causes, time distribution, and injury degree. Results ①The top three kinds of nursing adverse events were falls （45.8%） , escapes （ 15.8% ） , self-injury and hurt behav-iors （ 11.7% ） . ② The legal consequences of the most serious is the suicide, escape , self - injury and hurt behaviors of the inpatients. ③ More nursing adverse events （66.7%） was occurred on daytime. Conclusions The fundamental way of reducing the incidence of adverse e-vents is to improve staff arrangement, build up a safety culture, Improve nursing process, strengthen nurse training regularly to enhance their risk awareness and general quality. Moreover, it would be effective to reform the scheduling model and strengthen the health education based on mental disorder patients needs.