312例住院精神障碍患者护理不良事件原因分析及护理对策

Analysis of the Causes of Adverse Nursing Events in 312 Hospitalized Patients with Mental Disorders and Nursing Countermeasures

目的通过分析2年间312例不良事件发生的原因及特点,探讨如何避免不良事件的发生。方法回顾性分析厦门市精神卫生中心2017年10月—2019年9月护理系统上报的312例不良事件,对不良事件分类、发生原因、时间特点、损伤程度等进行研究。结果①住院精神障碍患者发生的护理不良事件前4位分别是伤人毁物(33.65%)、跌倒(29.49%)、自伤自杀(22.12%)擅自离院(4.81%)。②法律后果最严重的是患者的自杀自伤及伤人、外逃。③日间发生的不良事件多于夜间。结论找到护理不良事件的根本原因,提出有效的防范措施并全面落实,可以有效减低精神科护理不良事件的发生。

Objective To analyze the causes and characteristics of 312 adverse events in the past 2 years to explore how to avoid adverse events.Methods Retrospectire analysis of 312 adverse events reported by the nursing system of Xiamen Mental Health Center from October 2017 to September 2019,and the classification of adverse events,their causes,time characteristics,and degree of injury were studied.Results 1.The top four adverse nursing events in hospitalized patients with mental disorders were injury(33.65%),falls(29.49%),self-injury and suicide(22.12%)and leaving the hospital without authorization(4.81%).2.The most serious legal consequences are self-injury and self-injury by the patient,as well as escape.3.There are more adverse events during the day than at night.Conclusion Finding the root cause of adverse nursing events,proposing effective preventive measures and implementing them in full,can effectively reduce the occurrence of adverse psychiatric nursing events.