外科病区护理不良事件原因分析及对策

Cause Analysis and Countermeasures of Nursing Adverse Events in Department of Surgery

外科病区护理不良事件与护理质量、患者安全、护理管理等密切相关,已引起广泛关注。因此,分析不良事件产生的原因以及探讨其防范对策,对于护理工作具有重大意义。本研究选取本院外科病区2015年1月至2016年12月发生的68例护理不良事件进行分析,结果表明非计划拔管、跌倒/坠床、给药错误为高发事件;重症监护室、胸心外科、普外科为高发科室;观察不到位、评估不足、沟通不良为主要原因;白班、大夜班为发生不良事件的主要时段;低年资、低职称为主要涉事人员;未造成后果事件为主要事件。因此,护理不良事件的预防需要提高护士的专业服务能力,落实核心制度、合理配置护士人力资源,加强管理等措施减少护理不良事件的发生。

Adverse nursing events in surgical ward are closely related to nursing quality, patient safety, nursing management and so on, and it has caused widely public concerns. Therefore, analyzing the causes and exploring countermeasures of the nursing adverse events in department of surgery is of great significance for nursing. A total of 68 cases of nursing adverse events happened in department of surgery in Affiliated Women's hospital of Jiaxing University from January 2015 to December 2016 were analyzed. The results showed that the top kinds of nursing adverse events were unplanned extubation, falls and medication errors. The high risk departments of nursing adverse events were intensive care unit, cardiothoracic surgery, and general surgery department. The main causes were careless observation, inadequate assessment and ineffective communication. The main periods of adverse events were day shift and night shift. Most adverse events happened on nurse with low seniority or low professional title, as well as non-resulting-events were main events. Therefore, the prevention of nursing adverse events needed to improve the professional service ability of nurse, implement the core system, rationally allocate human resources of nurses, strengthen management, and take other measures to reduce the occurrence of nursing adverse events.