质量管理工具在护理不良事件分析与改进中的应用

Application of Quality Management Tools in the Analysis and Improvement of Adverse Events of Nursing

目的探索在护理不良事件分析与改进中如何运用质量管理工具。方法 2015年一季度,护士主动上报护理不良事件共计55件;运用柏拉图找出改进重点,以改进重点之一导管故障为例,运用柱状图、层别法、柏拉图、鱼骨图分析要因,针对要因拟定改进措施并实施。结果 2015年二季度、2016年一季度导管故障发生率均较2015年一季度下降。结论护理不良事件分析与改进需要准确选择质量管理工具,运用质量管理工具解决系统问题是护理不良事件管理的有效方法。

Objective To explore the use of quality management tools in the analysis and improvement of nursing adverse events.Methods In the first quarter of 2015,the nurse proactively reported 55 cases of nursing adverse events,the Plato was employed to find out the key point of improvement.One of the key points of improvement was the example of catheter failure.Using histogram,stratification,Plato,Fishbone Diagram to analysis of the main reasons for the proposed improvement measures and implementation.Results The rate of catheter failure in the second quarter of 2015 and the first quarter of 2016 were all decreased than the first quarter of 2015.Conclusion Analysis and improvement of adverse events need to select quality management tools accurately,and the use of quality management tools to solve system problems is the key of nursing adverse event management.