艾滋病病房医疗安全不良事件发生状况及预防对策

The occurrence of medical safety adverse events in acquired immune deficiency syndrome ward and preventive measures

目的研究艾滋病病房医疗安全不良事件发生状况及预防对策。方法回顾性分析2018年1月至2021年4月杭州市西溪医院艾滋病病房出现的81例医疗安全不良事件。分析医疗安全不良事件的发生类别及严重程度,并研究不良事件发生的原因及预防对策。结果81例医疗安全不良事件中发生医疗安全不良事件为74例(91.36%),医务人员职业暴露不良事件为7例(8.64%)。患者不良事件中安全隐患27例(33.33%),意外拔管25例(30.86%),压力性损伤13例(16.05%),给药错误9例(11.11%)。从事件等级分类情况来看,Ⅳ级事件58例(38.75%),Ⅲ级事件14例(55.00%),Ⅱ级事件9例(6.25%)。27例发生安全隐患事件中,18例为患者跌倒,9例为患者坠床;19例发生在日间,8例发生在夜间。25例意外拔管事件中,20例发生在夜间,5例发生在日间;16例发生在置管后1~3 d,7例发生在置管后4~7 d,2例发生在置管7 d后。13例压力性损伤事件中,Ⅰ期压力性损伤共10例,Ⅱ期压力性损伤共3例;10例合并感染性肺炎,3例合并肾功能损伤。9例给药错误事件中,护士均未严格按照给药流程对每次给药的药品数量、种类进行逐一核对。7例职业暴露事件中,5例为黏膜暴露,2例为针刺伤;从事件当事人身份上看,7例当事人均为院内护士;执业年限均在3年以内。结论艾滋病病房极易出现各类医疗安全不良事件,临床实践中应针对特殊病房患者采用更加全面的护理关怀和更加严格的质控管理,以避免各类不良事件的发生。

Objective To study the occurrence of medical safety adverse events in acquired immune deficiency syndrome ward and preventive measures.Methods A total of 81 medical safety adverse events in acquired immune deficiency syndrome ward of Xixi Hospital of Hangzhou from January 2018 to April 2021 were retrospectively analyzed.The categories and severity of medical safety adverse events in acquired immune deficiency syndrome ward were analyzed,and the causes and preventive measures of adverse events were studied.Results Among 81 medical safety adverse events,74 cases(91.36%)had adverse events of medical safety,and 7 medical staff(8.64%)had adverse events of occupational exposure.Among the adverse events,27 cases(33.33%)had safety hazards,25 cases(30.86%)had accidental extubation,13 cases(16.05%)had pressure injury,and 9 cases(11.11%)had administration errors.Judging from the classification of event levels,there were 58 cases(38.75%)of grade Ⅳ events,14 cases(55.00%)of grade Ⅲ events,and 9 cases(6.25%)of grade Ⅱ events.Among the 27 cases of safety hazards,18 patients fell and 9 patients fell out of bed;19 patients occurred during daytime and 8 patients occurred at night.Among the 25 cases of accidental extubation incidents,20 patients occurred at night and 5 patients occurred during daytime;16 patients occurred 1-3 days after catheterization,7 patients occurred 4-7 days after catheterization,and 2 patients occurred 7 days after catheterization.Among the 13 cases of pressure injury,10 patients were stage Ⅰ pressure injury and 3 patients were stage Ⅱ pressure injury;10 patients were complicated by infectious pneumonia,and 3 patients were complicated by renal impairment.In the 9 cases of drug administration errors,the nurses did not check the number and type of drugs administered one by one in strict accordance with the drug administration process.Among the 7 cases of occupational exposure incidents,5 cases were mucosal exposure and 2 cases were needle stick injuries;judging from the identity of the parties involved in the incident,the 7 parties were all in-hospital nurses;and they were all within three years of practice.Conclusion All kinds of medical safety adverse events are easy to occur in acquired immune deficiency syndrome ward.In clinical practice,more comprehensive nursing care and more strict quality control management should be adopted for patients in special wards to avoid all kinds of adverse events.