上海市三级甲等医院护理不良事件的调查

Investigation of Nursing Adverse Events in Class Ⅲ Grade Ⅰ Hospitals in Shanghai

目的了解上海市三级甲等医院护理不良事件的现状,分析其深层次原因,以期为改进护理工作流程、管理机制提供现实参考。方法 2014年10月至2015年2月,采用分层随机整群抽样方法,选择上海市4个不同经济水平区的4所三级甲等医院,在内科、外科、专科中随机抽取一个科室的护士及护生,采用基于关键事件技术的开放性问卷进行调查。结果按照不良事件发生频率,从高到低依次为护理操作相关事件(28.80%)、患者身份识别错误(25.28%)、给药错误(23.74%)、意外伤害(14.01%)、非计划拔管(8.17%)。结论通过增加护理人力配置、优化护士弹性排班,加强对低年资护士和实习护生的专业培训,建立无惩罚环境、完善护理不良事件报告系统,从而减少护理不良事件的发生。

Objective To understand the current status of nursing adverse events in Class Ⅲ Grade Ⅰ hospitals in Shanghai,and analysis the influencing factors,in order to provide clinical reference in improving nursing process and management mechanism.Methods By using stratified random cluster sampling,four Class Ⅲ Grade Ⅰ hospitals in Shanghai were selected.The nurses and nursing students were randomly selected from departments of internal medicine,surgical department and specialist department.The participants were interviewed by using questionnaire based on critical incident technique.Results The frequencies of adverse events from high to low in sequence were nursing operation related events （28.80％）,patient identification error （25.28％）,medication mistake （23.74％）,accidental injury （14.01％）,unplanned extubation （UEX） （8.17％）.Conclusions Increasing nurse staffing,optimizing flexible scheduling,strengthening training for the young nurses and nursing students,creating a non-punitive working environment and improving the adverse events reporting system can reduce the incidence of nursing adverse events.