精神科护理不良事件的原因分析及对策

Reason Analysis and Countermeasures of Psychiatric Nursing Adverse Events

目的分析精神科护理不良事件发生的原因,为患者安全和风险管理提供依据。方法对某三级甲等精神病专科医院2010年～2012年上报的89例护理不良事件进行回顾性分析。结果精神科护理不良事件排在前三位的是攻击行为(26.9%),跌倒、坠床(21.3%),走失(16.9%);发生原因排前三位的是风险意识差(37.1%)护士责任心不强(16.9%)及规章制度未落实(14.6%)。结论精神科护理服务有其特殊性,护理不良事件的发生,既有人为因素,又有系统因素。运用根本原因分析法,综合考虑这两方面因素,对护理不良事件进行分析和处理,才能营造健康的护理安全文化环境。

Objective To analyze the causes of psychiatric nursing adverse events, and provide the basis for the safety and risk management of patients. Methods A retrospective analysis was made on 2010 to a three level of first-class psychiatric hospital reported in 2012 89 cases of nursing adverse events. Results Psychiatric nursing adverse events in the top three are aggressive behavior （26.9%）, falling down, falling out of bed （21.3%）, （16.9%）; lost causes ranked the top three is the risk consciousness difference （37.1%） nurses responsibility heart is not strong （16.9%） and the regulations do not implement （14.6%）. Conclusion Psychiatric nursing services has its particularity, the nursing adverse events, both human factors and system factors. Using root cause analysis method, considering these two factors, analysis and processing of the nursing adverse events, to build safety culture in nursing and healthy environment.