根本原因分析法在综合医院住院患者自杀事件预防中的运用

Application of root cause analysis on prevention of suicide amonggeneral hospitalpatients

目的通过对某综合医院住院患者自杀情况调查分析,探讨住院患者自杀原因及预防、干预措施。方法采用根本原因分析法,对护理不良事件系统中患者自杀事件的上报资料和病历资料进行分析,并访谈发生自杀事件的主治医生、病房护士长、责任护士、当班护士和患者家属,运用鱼骨图确定患者自杀的近端原因与根本原因并制订改进措施。结果坠楼是住院患者选择的主要自杀方式;患者自身负性情绪管理不当,缺乏合适评估机制对住院患者进行心理评估和缺乏对护士进行患者心理问题的观察与应对能力的培训是影响患者自杀的根本原因。结论医护人员应加强患者负性情绪管理,建立自杀高危患者的心理评估体系,加强护士心理护理能力培训,加强护士与患者及家属沟通,完善医院安全保障制度等措施防范住院患者自杀的发生。

Objective Based on the investigation and analysis of the situation of suicidcinpatients in general hospital,to explore the causes and preventive measures of suicide. Methods Using root cause analysis method,the data andmediealrecords reported nursingadverseevents in patients Dutchact system events wereanalyzed,and the familymembersofpatients interview, responsible doctor, professor, headnurses, responsiblenurses and nursesonduty were interviewed, then fish bone diagram was used to determine the proximal causes and root causes in patients with Dutch act,and then formulate improvement measures. Results The high - riskgroups of Dutchact includedpatients with long severe disease, cancer of bad treatment effect, history of mental illness and physical pain or sleep disor- der. Fallfrom building was main way of Dutchaet. patientslnismanagement of negativeemotion, lackofappropriate evaluation mechanism for psychological assessment and the lack of training for nurses to observeand appropriately response topsychologicalproblemswere the root causes of patients＇Dutchact. Conclusion Measures of preventing hospital inpatient suieideinclude mediealstaffcompensatingforinadequate management of patients with negative emotions, developing high risk of sui- eideevaluation system,to strengthen the training of nurses＇psychological nursing ability, to strongthenthe communicationwithpatientsandtheirfamilies, to improve the security system and etc.