学习型不良事件管理团队的建立与成效

The establishment and the effect of the learning-oriented management team for ad-verse events

目的：加强不良事件报告、分析和反馈，规范不良事件管理，完善患者安全管理系统，从而改善患者安全。方法建立由跌倒、给药、管路护理和伤口造口专业小组组成的学习型不良事件管理团队，梳理护理不良事件管理中存在的问题，制订职责及三级管理制度，实行目标管理，强化经验交流与学习，落实督查和持续改进管理措施，并建立不良事件数据库。结果运行6个月，共收集不良事件207件，提高了上报率和不良事件的种类，从不良事件中吸取经验并修正安全管理系统，达到“完善工作流程并落实培训，有评价与持续改进”的不良事件管理目标，同时增强护理安全意识，营造了安全文化氛围。结论学习型不良事件管理团队利用不良事件上报的数据，改善患者安全管理的文化环境，形成全院性的不良事件报道和经验交流系统实践共同体，提高了管理效率，保障了患者安全。

Objective To strengthen the report, analysis and feedback of the nursing adverse events, and to standardize the management of the adverse events, and improve the safety management system for patients, so as to im-prove patients＇ safety. Methods The learning-oriented management team for adverse events was set up, composed of falling, drug administration, pipeline care and wound colostomy professional team. The team teased out the nursing management problems that exist in the adverse events, formulated the responsibilities and three-grades management sys-tem, conducted target management, strengthened the exchange of experience and learning, carried out the supervision and improved the management measures continuously, and established the database of adverse events. Results The management team received 207 cases of adverse events in 6 months. This practice improved the type and the reporting rate of adverse events,learned lessons from the adverse events and fixed safety management system in order to achieve the aim of promoting the workflow processes and carring out trainings, timely evaluation and continuously improvement. Meanwhile, the nurses＇ safety awareness and safety culture atmosphere were strengthened. Conclusions The learning-oriented management team improved the safety culture atmosphere with the help of these reported data of adverse events and formed a practicing community over the whole hospital aiming at reporting adverse events and exchaging experi-ence. The management efficiency has been improved and the patients＇ safety has been ensured.