护理不良事件原因分析

Cause analysis of nursing adverse events and countermeasures

目的:通过对护理不良事件的归因分析,寻找护理不良事件发生的薄弱环节,为护理风险管理和保证患者安全提供依据。方法:采用回顾性调查的方法,对眉山市第二人民医院2012年1月-2013年10月护理系统主动上报的护理不良事件共67例进行分类统计,并作分析。结果:护理不良事件按发生例数依次为:难免压疮21例,占31%,投诉10例,占15%,跌倒8例,占12%,输液不良反应8例,占12%,管道事件7例,占10%,采血错误7例,占10%,药物外渗3例,占4.5%,患者走失2例,占3%,用药错误1例,占1.5%。结论:对护理不良事件进行分析,采取有效的干预措施,减少跌倒、输液反应、投诉事件、管道脱落的发生,能有效降低护理不良事件的发生。

Objective To analyze the causes of nursing adverse events and to explore the effective measures in order to reduce nursing adverse events.Methods After reviewing the 67 nursing adverse events which took place in the Second Hospital of Meishan during January 2012 and October 2013,we analyzed the type,cause and the situation of the parties.Results The main causes of nursing adverse events were violation of operating rules and system,lack of responsibility and poor service attitude.The types of nursing adverse events mainly included inevitable sore（21cases,31%）,complaint（10cases,15%）,adverse reactions（8cases,12%）,tube dropoff（7cases,10%）,and medication errors,injuries and dropping from bed etc.Conclusions Analysis of nursing adverse events,effective intervention measures and reduction in the occurrence of fall,adverse reactions,complaints and tube dropoff can decrease nursing adverse events effectively.