146例护理不良事件原因分析及对策

Causes analysis of 146 nursing related adverse events and corresponding measures

目的 总结146例护理不良事件发生原因,提出可行性防范对策.方法 回顾性分析苏州市中西医结合医院2014年1月-2015年6月上报的146例护理不良事件,总结不良事件发生原因和特点.结果 不良事件类型包括医嘱执行错误、管道脱落/拔出、跌倒、操作失误等,其中医嘱执行错误56例（38.36％）,分析原因为查对制度执行不到位、违反操作规程等.管道脱落/拔出30例（20.55％）.护理不良事件多发生于日班时间、1～5年工龄的护士中.结论 利用“3E”对策理念制定针对性的护理措施,从而降低护理不良事件的发生率,提高护理质量.

Objective To analyze the cause of 146 nursing related adverse events and to provide preventive measures. Methods A total of 146 nursing related adverse events reported be- tween January 2014 and June 2015 were retrospectively analyzed, and the causes and features of ad- verse events were analyzed. Results Major adverse events included execution error of medical or- der, catheter removal or falling, falling and inaccurate operation. Execution error of medical order, accounting for 38.36% （56/146）, was caused by lack of accurate execution, and violation of opera- tive regulation. There were 30 cases with catheter removal or falling, accounting for 20.55 % （ 30/ 146）. Nursing related adverse events were more likely to occur during day shifts and in nurses with less than five occupational years. Conclusion Targeted nursing intervention implemented by 3 E concept can reduce adverse events and improve nursing quality.