新生儿坠床事件1例原因分析

Causes Analysis of One Case of the Neonatal Falling Bed Event

目的:通过对住院新生儿坠床事件原因进行分析,帮助护理管理者和分析人员理清思路,提高分析能力,更好地辨别事件发生的根本原因,提出改善对策与防范措施。方法:对2013年8月产科病房发生的1例新生儿坠床事件,依次应用时序表、因果表、流程图、鱼骨图、流程解构图、改善对策执行管理表等工具进行逐层分析。结果:住院新生儿的坠床事件不仅因缺少婴儿床的使用流程有关,还与设备科对临床科室设备的管理、护理人员交接班交接内容等方面都有关系。结论:对坠床事件的各种危险因素进行了全面分析,并制定了一系列相应预防干预措施,从而证明了护理安全风险防范在临床护理工作中的重要意义,要求护理人员在护理工作中加以落实和实施,确保住院新生儿的人身安全。

Objective To help nursing managers and analysts to clarify ideas,improve the analysis ability,identify the fundamen-tal reason of events,put forward countermeasures and preventive measures by analyze causes of the neonatal falling bed events.Meth-ods Timing table,causation table,flow chart,fishbone diagram,process deconstruction diagram,and countermeasures to improve ex-ecution management table and other tools was used to perform analysis layer by layer for neonatal falling bed events in August 2013 in our hospital of maternity ward.Results The reasons of neonatal falling bed events were not only because of the lack of a baby＆#39;s bed use process,but also clinical departments device management and nursing shift handover content.Conclusion The risk factors of falling bed events are analyzed,and a series of corresponding prevention measures are formulated,which proves that the nursing safety risk prevention is significant in clinical nursing work,requests nursing staff to implement nursing work and ensure the personal safety of hos-pitalized neonates.