某三甲医院3160例不良事件回顾性分析

A Retrospective Analysis of 3,160 Adverse Events in a Hospital of Class One,Grade Three

目的探讨医疗不良事件报告规律,为防范医疗风险提供依据。方法对2013—2015年3 160例不良事件进行回顾性分析。结果 2013—2015年各年度每百张床位报告件数分别为52.88、57.34、75.14,平均值为62.57,年度差异显著(P<0.001);Ⅱ级及以上事件构成比为1.77%、2.76%、3.19%,年度构成差异明显(P<0.001);医嘱或处方不当、调剂错误、在院压疮、药品不良反应、跌倒与坠床、管路滑脱、针刺伤、输血不良反应事件连续三年居前八位。其中医嘱与处方问题、在院压疮、针刺伤、管路滑脱事件年度报告增加有统计学差异(P<0.001)。结论无责报告、对报告者实施奖励可以有效提高不良事件的报告件数、员工参与度,对提高不良事件报告率、防范医疗风险具有重要意义。

Objective: To discuss the report regularity of medical adverse events,and provide the basis for preventing medical risks. Method: The authors made a retrospective analysis on 3,160 cases of adverse events from 2013 to 2015. Result: The annual report number every hundred beds are 52. 88,57. 34 and 75. 14 respectively from 2013 to 2015,w ith an average of 62. 57 and a significant difference( P < 0. 001); The constitute ratios of RankⅡand above events are 1. 77%,1. 77%,and 2. 76%,w ith the annual significant difference( P < 0. 001); and the improper medical advice or prescription,dispensing errors,pressure sores in hospitalization,adverse drug reaction,falls and bed fallings,pipe line slips,needle stick injuries,and the adverse events of blood transfusions are on the top 8 in the consecutive 3 years. There w as the statistical difference of( P < 0. 001),related w ith the increased annual reports on doctor's improper advice or prescription,pressure sores in hospitalization,needle stick injuries,pipe line slips,and the adverse events of blood transfusions. Conclusion: It is of great significance to improve the reporting number of adverse events,employee engagement,and the reporting rate of adverse events,and prevent medical risks by means of reporting w ithout responsibility and rew arding the reporters.