ICU护理不良事件主动非惩罚奖励性内网上报分析研究

Study on the reporting of adverse nursing events in ICU by active non-punitive and rewarding intranet

目的分析重症监护病房(intensive care unit,ICU)护理不良事件主动非惩罚奖励性内网上报的效果。方法回顾2017年—2019年ICU内网上报的141例不良事件,对ICU护理不良事件发生的类型、级别、原因、时段、护士层级、工作年限进行分析。结果ICU护理不良事件上报率逐年上升,发生主要原因为评估不到位、带教不到位、培训不到位、沟通不足。ICU护理不良事件主要类型为:管路、院内压疮、药物、医疗处置。ICU护理不良事件主要为Ⅲ级及Ⅳ级事件,Ⅲ级事件逐年下降。ICU护理不良事件与发生时段、护士层级、护士工作年限相关。结论ICU实施主动非惩罚奖励性内网上报可有效提高护理不良事件上报率;采取“错误分享”及典型护理不良事件全院交流分享后,Ⅲ级护理不良事件的发生得到有效预防及降低。应加强对低年资护理人员的分层、重点、全覆盖培训,以及护士对患者病情的评估和沟通能力。

Objective Analyze the active non-penalty reward intranet reporting of adverse nursing events in the Intensive Care Unit(ICU).Methods Review 141 adverse events reported by ICU Intranet from 2017 to 2019,and analyze the types,levels,causes,periods,nurses'grades and working years of adverse events in ICU.Results The number of adverse nursing events reported in ICU was gradually increasing,mainly due to inadequate assessment,inadequate communication,inadequate management and inadequate teaching.The main types of ICU nursing adverse events:pipeline,hospital pressure sores,drugs,medical treatment.ICU nursing adverse events mainlyⅢlevel andⅣlevel events,andⅢlevel events decline year by year.Adverse nursing events in ICU were related to the time of occurrence.The occurrence of adverse nursing events in ICU was related to nurse grade.The occurrence of adverse nursing events in ICU is related to the working years of nurses.Conclusion For ICU active non-punitive incentive Intranet report,the reporting rate of adverse events was effectively improved and the rate of omission and concealment was significantly reduced.Adopting the"error sharing"method and typical events to communicate and share with the whole hospital can effectively prevent or reduce the occurrence of theⅢlevel nursing adverse events.According to the causes and types of adverse nursing events in ICU combined with the actual situation of the department,nursing staff with low seniority are the main group of adverse nursing events in ICU.Stratified,focused and full-coverage training is adopted for nursing staff with low seniority to strengthen nurses'assessment and communication of patients'conditions.