55例精神科护理不良事件原因分析及应对策略

Cause analysis and coping strategies of adverse nursing events in psychiatric department

目的：分析精神科发生护理不良事件的原因与特点,并提出相应对策,降低精神科护理不良事件的发生率。方法：回顾性调查本院2013年1~12月55例患者发生的护理不良事件,了解其发生原因、分类、损伤结局、发生时间及地点等。结果：精神科护理不良事件发生频率前3位依次为跌倒致伤（包括坠床）9例、患者冲动（包括工作人员粗暴对待患者）6例、外走5例;38例（69.09%）不良事件导致患者不同程度的损伤,排前3位不良事件中跌倒导致患者轻中度损伤发生率最高;不良事件发生率最高两个时间段分别为7∶00~10∶00时与17∶00~18∶00时;护理不当是导致不良事件发生的主要原因,其中初级职称护士及护龄在10年以下护理人员不良事件发生率最高。结论：应加强病房安全管理,规范护理管理流程,合理配置与安排护理人力资源,重视提高低职称、低学历护理人员护理风险防范意识及规范化培训,从而减少护理不良事件的发生。

Objective ：To analyze the causes and characteristics of adverse nursing events in psychiatric department and put forward the reduce the incidence of adverse nursing events. Methods ： We retrospectively investigated 55 cases of adverse nursing events in our hospital from January to December in 2013 to know about their causes, classifications, injury outcomes, the occurred times and places of occurrence. Results：It showed that the top three adverse nursing events in psychiatric department were 9 cases of falling injuries （ including falling down from bed） ,6 cases of patient＇s impulsive be- havior （ including staff manhandled patients）, and 5 cases of walking out of the hospital ; and other 38 cases injured to different extend by adverse events. A- mong the top three adverse events ,falling had the highest incidence rate of mild to moderate injuries in patients The two time periods with the highest rate of adverse events were 7： 00 to increase 10：00 in and 17： 00 - 18： 00 pm ; improper nursing was the main reason for the occurrence of adverse events, and the junior nurses and nurses with nursing age less than 10 years had the highest rate of adverse events. Conclusion ： We should strengthen the safety management of wards, standardize the nursing management process, reasonably allocate and arrange nursing human resources, and pay more attention to improve the risk prevention awareness of the nurses with low professional tides, low education background and provide them with standardized trainings, so as to reduce the occurrence of adverse nursing events.