39例护理不良事件原因分析与对策

Cause analysis and countermeasures based on 39 case reports of nursing adverse event

目的分析护理不良事件的发生原因,探讨相应干预对策。方法收集2012年1月—2014年12月上报的护理不良事件39例的相关资料,采用鱼骨图分析法对事件发生的种类、时间、不同科室分布规律及人员结构状况进行分析,并提出针对性的防范措施。结果白班中护理不良事件发生比例最高,占59.0%;护士中发生比例最高,占51.3%,而在主管护师和实习护士中发生比例最低;综合传染科发生比例最高,占25.6%。按不良事件发生因素分类,发生率较高的因素包括患者因素(20.5%)、培训不到位(17.9%)、评估不足(15.4%)和违规操作(12.8%);按类型分类,职业暴露发生最多(46.2%),其次为患者安全管理类(25.6%)和跌倒/坠床(20.5%)。结论制定规范的护理管理制度和流程,增强护理人员的风险意识和识别能力,科学合理地配置人员结构,强化知识和技能培训,加强安全管理与质量监控,能有效预防临床护理不良事件的发生。

Objective To analysis the causes based on 39 case reports of nursing adverse event and to provide potential countermeasures. Methods To retrospectively collected the clinical data of 39 case reports of nursing adverse event between Jan 2012 to Dec 2014. The Fish Bones method was applied to investigate the pattern of category,time,distribution and staff structure in 39 case reports of nursing adverse event. Results The nursing adverse event was most likely reported in day shift( accounting for 59. 0%),and was more common in those general nurse( accounting for 51. 3%) than supervisor nurse or practicing nurse. The incidence of nursing adverse event in department of General Infection Disease ranked the most,which was 25. 6%. The primary reason of nursing adverse event was patients issues( 20. 5%),followed by insufficient training( 17. 9%),inadequate assessment( 15. 4%) and violation operation( 12. 8%). In terms of event type,the occupational exposure( 46. 2%),safety management( 25. 6%) and accidently falling down /falling of bed( 20. 5%) were main types of adverse events in nursing. Conclusion Measures such as standardization of nursing procedure,reinforcement of risk awareness and recognition capability,effective nursing staffing allocation,strengthening safety management should be carried out to prevent the nursing adverse event.