基于患者安全理念的护理不良事件分析及策略

Analysis and Strategies of Adverse Nursing Events Based on Patient Safety Concept

目的分析护理不良事件,明确导致不良事件发生的危险因素,进而提出干预措施,为保证患者安全提供策略依据。方法回顾性分析某三级医院儿科2017年1月~12月上报的不良事件,分别从发生类别、科室、时段、职称、工作年限等进行统计。结果共收集不良事件报告83例,男性多余女性,主要集中于年龄<1岁年龄段。83例儿科护理不良事件分为8类,发生率排名前3位的依次是不良治疗事件、意外事件、管道护理事件,分别占全年不良事件的45.78%、19.28%、7.23%。上报数量居首位的科室是儿科重症监护室(简称PICU),其次为儿科二区。白班和上夜是发生不良事件的薄弱时段。不同职称、工作年限护士发生护理不良事件构成比比较,差异有统计学意义(P<0.05),其中护士/护师、工作年限≤5年的年轻护士是发生不良事件的主要责任人。结论年轻护士人群、夜班时段是不良事件发生的普遍危险因素,应对以上人群、时段进行重点监控。

Objective To analyze the adverse events of nursing,to clarify the risk factors that lead to the occurrence of adverse events,and then to propose intervention measures to provide a strategic basis for ensuring patient safety.Methods A retrospective analysis of the adverse events reported in the pediatrics department of a tertiary hospital from January to December 2017 was carried out based on the occurrence category,department,time period,title,and working years.Results A total of 83 reports of adverse events were collected.Males were more than females,mainly in the age group less than 1 year old.The 83 cases of pediatric nursing adverse events were divided into 8 categories.The top 3 incidences were adverse treatment events,accidental events,and pipeline nursing events,accounting for 45.78%,19.28%,and 7.23%of the annual adverse events,respectively.The department with the largest number of reports was the Pediatric Intensive Care Unit(PICU),followed by the Pediatric Division II.Day shifts and nights were weak periods for adverse events.Comparing the composition ratio of adverse nursing events among nurses with different professional titles and working years,the difference was statistically significant(P<0.05).Among them,nurses/nursing nurses and young nurses with a working life of≤5 years were the main responsible persons for adverse events.Conclusion The young nurse population and night shift period are common risk factors for adverse events.The above population and period should be monitored.