云南省某综合三级甲等医院349例护理不良事件分析

Analysis of 349 cases of nursing adverse events in a comprehensive tertiary hospital in Yunnan province

目的 分析护理不良事件,为制订预防措施,提高护理质量管理,防范医疗风险提供依据。方法回顾性分析云南省某综合三级甲等医院近5年各科室主动上报的349例护理不良事件。结果 349例护理不良事件中,发生频率最高的前5位分别是跌倒/坠床、用药错误、非计划性拔管、压力性损伤、液体外渗;62.75%的不良事件对患者造成了不同程度的损害;16:00—18:00,10:00—12:00,08:00—10:00是不良事件发生的高峰时段;男性和高年龄段患者占多数;大专学历和本科学历是不良事件上报者的高发人群,低年龄段和初级职称护士是发生不良事件的高危人群。结论 护理不良事件的发生是多因素的,医院除了加强护理个人能力培养,完善相关制度外,还应建立风险预警体系,及早识别潜在高危人群,预防护理不良事件的发生。

Objective To analyze the adverse events of nursing,to provide the basis for formulating preventive measures,improving nursing quality management,and preventing medical risks.Methods A retrospective analysis of 349 cases of adverse nursing events reported by various departments in a comprehensive tertiary fi rst-class hospital in Yunnan province in the past 5 years was retrospective.Results Among the 349 nursing adverse events,the top fi ve with the highest frequency were fall/fall from bed,medication error,unplanned extubation,pressure injury,and fl uid extravasation;62.75% of the adverse events caused dif ferent degrees damage to patients;the 16:00—18:00,10:00—12:00,08:00—10:00 were the peak periods of adverse events;the majority of patients were males and older age groups;the college education and undergraduate education were the high-risk groups for reporting adverse events,and the low-age and junior professional nurses were the high-risk groups for adverse events.Conclusion The occurrence of adverse nursing events was multi-factorial.In addition to strengthening the training of nursing personal ability and improving relevant systems,hospitals should also establish a risk early warning system to identify potential high-risk groups early and prevent the occurrence of adverse nursing events.