开展安全案例讨论及标兵竞选 降低护理不良事件

REDUCING NURSING ADVERSE EVENTS BY SECURITY CASES DISCUSSION AND PACESETTER ELECTION

目的探讨安全案例讨论及标兵竞选在护理不良事件管理中的应用及效果。方法建立非惩罚护理不良事件报告的激励机制,对已发生的护理不良事件,每季度进行分类统计、分析及开展典型案例分享讨论会;对于潜在的安全隐患,每季度举办"安全护理标兵"的事迹交流及竞选活动,鼓励护士讲述自己发现并堵塞医疗、护理漏洞,确保患者安全的真实、典型事例,供大家分享、警示。结果实施后比实施前护理不良事件的漏报率及发生率均明显下降(p<0.001,p<0.01)。结论开展护理安全案例讨论及标兵竞选可有效提高护士对护理安全风险的识别、评估、处理及防范能力,降低护理不良事件发生率。

Objective To discuss on the applications and effects of security cases discussion and pacesetter election on the management of nursing adverse events. Methods The incentive mechanism of non- punishment nursing adverse events report was established. The occurred nursing adverse events were quarterly statistically classified and analyzed and the typical cases were discussed. The experiences sharing activity and election of nursing security pacesetter were hold quarterly to solve the issues in potential security. Nurses were encouraged to share their real and typical case of ensuring patients’ safety by finding and closing medical and nursing loopholes. Results After the implementation of security cases discussion and pacesetter election,the rate of missing report and incidence of nursing adverse events were decreased significantly（ p 〈 0. 001,p 〈 0. 01）. Conclusion The nursing security case discussion and pacesetter election can effectively reduce the incidence of nursing adverse events by enhancing nurses’ ability on distinguishing,estimating,handling and preventing nursing security risk.