免责直报系统结合PDCA循环模式对护理不良事件的影响

Study for the effects of disclaimer network reporting system combines with PDCA cycle mode for nursing adverse events

目的探讨护理质量与安全管理全程中，贯穿免责网络直报系统、PDCA循环对护理不良事件上报及发生情况的影响，为“患者安全行动”提供科学的管理工具和体系。方法2012年1月依托医院内网络系统，构建护理不良事件网络直报系统，结合PDCA循环计划、实施、检查、处理四个步骤，对所上报事件通过分析，提出改进措施、共享不良事件的信息资源，对能解决的进行推广，对不能解决的进入下一个循环，观察实施前（2011年）和实施后第1年（2012年）不良事件主动上报率及2011-2013年三年护理不良事件上报情况。结果2012年护理不良事件上报363例，高于2011年118例，差异有统计学意义（X^2=151．285，P=0．000）；2011～2013年三年护理不良事件上报情况差异有统计学意义（X^2=181．629，P=0．000）；2013年护理不良事件上报240例低于2012年363例，差异有统计学意义（X^2=52．612，P=0．000）。结论免责直报护理不良事件系统结合PDCA循环，作为一个整体贯穿于护理质量与安全管理全程中，能有效降低护理不良事件发生率，体现了持续质量改进的远期效果，利于为患者和护理人员营造安全文化环境。

Objective To study the effects of disclaimer network reporting system, PDCA cycle with quality of care and safety management on nursing adverse event reports and occurrence, and to provide scientific management tools and systems for the global ＂Patient Safety Initiative＂. Method Based on establishment of nursing adverse event reporting system and combination of four steps included PDCA cycle planning, implementation, inspection, handling on January 2012 to analyze the adverse event reports, to provide improvements adverse, sharing＂error＂ resources. The solve problems were promoted. The active reporting rates of adverse events before and one year after implemen- tation was measured respectively in 2011 and 2013, the reported cases from 2011 to 2013 were compared. Result Nursing adverse events reporting in 2012 was higher than that in 2011 （ 118 vs 363 ）, there was significant differ- ence （X^2= 151. 285, P= 0. 000）. The adverse events reporting for three years were significant difference （X^2=