SHEL模式在分析护理不良事件发生中的应用

The application of SHEL model in analysis of nursing adverse events

目的分析护理不良事件的发生原因,揭示发生原因的决定因素,从而制定相应对策。方法应用SHEL模式对114例护理不良事件,按照软件、硬件、临床环境、当事人及相关人4个项目,进行原因归类分析。结果护理不良事件发生原因护士业务素质和能力的软件因素58例(50.88%),护理工作场所及设施的硬件因素20例(17.54%),临床环境因素29例(25.44%),当事人及他人因素44例(38.68%)。结论不良事件的发生,既有个人原因、可控制因素,也有系统原因、不可控制因素。提高护士业务素质和能力的软件实力,改善工作场所、设施的硬件建设,营造安全"临床环境",增强患者及家属良好依从性、充分掌握防护知识,是提高护理安全质量的根本途径。

Objective To analyze the causes of nursing adverse events,reveal the determinants of the causes,and formulate corresponding countermeasures. Methods One hundred and fourteen cases of nursing adverse events were classified by SHEL mode,according to the four items including software,hardware,clinical environment,litigants and related persons. Results The software factors of nurses＇ professional quality and ability were in 58 cases（ 50. 88%）,20 cases（ 17. 54%） had hardware factors for nursing workplace and facilities,29 cases（ 25. 44%） for clinical environment factors and 44 cases（ 38. 68%） for litigants and related persms. Conclusion The occurrence of adverse events includes personal reasons,controllable factors,systematic causes and uncontrollable factors. The fundamental way to improve the quality of nursing safety is to improve the software strength of the nurses ＇professional quality and ability,to improve the hardware construction of the workplace and facilities,to create a safe ＂ clinical environment＂,to enhance the good compliance and protection knowledge of the patients and their families.