医疗安全（不良）事件根因分析及对策研究

Root causes analysis of medical safety （adverse） events and counter measures research

目的探讨医疗安全（不良）事件的特征及原因，提出防范对策。方法对322例医疗安全（不良）事件进行根因分析。结果身份识别错误、医疗缺陷、药物事件为高发事件，分别占16．77％（54／322）、16．15％（52／322）、13．98％（45／322）；神经内科、普通外科、肿瘤科为多发科室，分别占9．63％（31／322）、7．45％（24／322）、7．14％（23／322）；中级和副高级职称人员为主要涉事医务人员，分别占33．23％（107／322）、25．78％（83／322）；护理人员居首，占56．83％（183／322）；大夜班为发生最高时段，占39．75％（128／322）；护理不当、操作违规、监管不到位为引发事件的具体行为，分别占17．39％（56／322）、15．84％（51／322）、15．22％（49／322）；三级未造成后果事件发生最多，占47．20％（152／322），医患双方协商是解决问题的主要方式，占82．26％（51，62）。结论医疗安全（不良）事件的预防需要加强重点科室的监管，做好重点环节的防范，加强医患沟通及医务人员风险意识，加强支持系统建设，及时发布预警信息。

Objective To analyze characters and causes of medical safety （adverse） events and to propose corresponding countermeasures. Methods 322 medical safety events in some tertiary hospitals were analyzed by using the root causes analysis method. Results Identifying errors, medical defects, medicine mistakes were the top 3 events possessed 16.77% （54/322）, 16.15% （52/322）, 13.98% （45/322）; The top 3 departments were Neurology, General surgery, Ontology which possessed 9.63% （31/322）, 7.45% （24/322）, 7.14% （23/322）. Medical staff with a title of middle and highly were involved in possessed 33.23% （107/322）, 25.78% （83/322）, and nursing staff was the top one possessed 56.83% （183/322）. Night working shift was the maximum occurrence time possessed 39.75% （128/322）. The top 3 medical acts which more easier to trigger medical adverse events were incomprehensive nursing care, irregtdar operation of diagnosis and treatment, clinical supervision defect which possessed 17.39% （56/322）, 15.84% （51/322）, 15.22% （49/322）. The slight consequence case was the top one possessed 47.20% （152/322）. Resolving the dispute by consultation between hospital and patient was the main way possessed 82.26% （51/62）. Conclusions More attentions should be paied to supervision of some certain department management and key sections, and improve the professional technical level, do preventive construction systems about medical safety （adverse） as well as emergency event handling construction mechanism by consummate supporting system and effective staff arrangement.