信息系统支持下26例小儿患者相关护理不良事件分析及管理对策

Analysis of 26 Cases of Nursing Related Adverse Events in Children With the Support of Information System

目的分析26例小儿患者相关护理不良事件的特点及原因,为制定有效预防措施提供依据。方法对某三级甲等综合性综合医院2016年度护理系统上报的26起患儿相关护理不良事件进行回顾性分析。结果所有护理不良事件均24小时内完成系统报告;5岁以下患儿所占比例最大占(73.1%);输液渗漏占首位(46.15%);未造成伤害事件发生率最高,占50.0%;8月为不良事件发生的高峰月份,而12:00—15:59时间段是不良事件高发时间段;发生原因中患者因素(包含疾病所致及血管条件等)占30.9%,技术不熟练和查对不严均占15.4%。结论应以HIMSS7级建设为抓手,应用科学质量管理工具,从循证护理角度出发,寻找最佳改进方法 ;加强员工在职培训,提高穿刺技术;优化排班模式、弹性排班,并做好质量监控,从系统根源避免护理不良事件发生,保障患儿安全。

Objective To analyze the characteristics and reasons of nursing relatively adverse events in26pediatric patients and to provide reference for making out the measure of effective prevention.Methods A retrospective analysis was conducted on26cases of nursing relatively adverse events of pediatric patients recruited from the Nursing System in a Three Grade Hospital in2016.Results All adverse events were reported within24hours,of which patients less than5years old accounted for the largest percentage(73.1%),with46.15%were transfusion infiltration,and no harm events accounted for the largest percentage(50.0%).The peak morbidity time was August and the time quantum was12:00-15:59.Three factors consisted of the major reasons of the adverse events:patients’factor(30.9%),unskilled(15.4%)and careless checking(15.4%).Conclusion With the opportunity of building of HIMSS7level,methods of scientific quality management should be applied to improve the nursing quality from the perspective of evidence-based nursing.The training should be strengthened to improve the level of puncture technique.Optimize the arrangement and quality monitoring should also applied to avoid the happen of nursing relatively adverse events to ensure the safety of patients.