护理事故差错原因的“冰山角”模型分析

＂Tip Angle＂model analysis on the reasons of nursing mistakes

目的 对护理事故差错原因进行表面原因、过渡原因和根本原因的分类,便于提出对策.方法 采用文献查询法和头脑风暴法,提出护理事故差错的原因,合并雷同原因,使用“冰山角”模型进行分类分析.结果 责任心不强、工作负荷大、职业作风不严谨、监督机制欠缺、护理人员配置不足为根本原因,医疗缺陷为表面原因,其余为过渡原因.结论解决护理事故差错的关键是加强责任心的培养,形成严谨的职业作风;配置充足的护理人员,减轻护理人员工作负荷;完善监督机制,加强监督.

Objective To classify the reasons of nursing mistakes into surface reason,transit reason and fundamental reason,so as to raise solutions.Methods Through literature queryand brainstorming,we found out the reasons of nursing mistake,merged similar reasons and classified the reasons with ＂Tip Angle＂ model.Results Lack of responsibility,overload of work,less rigorous handling,incomplete supervision system,and insufficient nursing staff were the fundamental reasons.Medical care defect was the surface reason.And all others were transit reason.Conclusions The key to resolve nursing mistakes is strengthening responsibilities,forming a rigorous handling,replenishing nursing staff and easing their workload,together with improving supervising system and strengthen supervising.