鱼骨图原因分析法联合SHEL模式在住院患者跌倒事件中的应用

Application of fishbone diagram analysis combined with SHEL model in hospitalized patients with falls

目的 运用鱼骨图原因分析法对32例住院患者发生跌倒情况进行分析,联合SHEL模式制定住院患者发生跌倒的防范措施,降低住院患者的跌倒发生率。方法 回顾性分析某三甲医院2009-2019年32例住院跌倒患者的病历资料,运用鱼骨图工具描述跌倒不良事件发生的因素:环境因素、护理因素、管理因素、患者及家属因素。采用SHEL模式即软件部分(soft,S)、硬件部分(hard,H)、临床环境(environment,E)以及当事人和他人(1itigant,L)4个方面对跌倒事件进行管理,比较干预前后2年间住院患者跌倒事件的发生情况,采用Fisher精确检验鱼骨图原因分析法联合SHEL模式干预效果。结果 根据鱼骨图原因分析法结果,采用SHEL模式管理后,经Fisher精确检验,住院患者跌倒事件干预前后比较,差异有统计学意义(P<0.05)。结论 鱼骨图原因分析法联合SHEL模式制定预防措施能够有效降低住院患者的跌倒发生率。

Objective To analyze the falls of 32 inpatients by using fishbone diagram,and with the help of the SHEL model to develop measures for the prevention of falls among hospitalized patients,so as to reduce the rate of falls in hospitalized patients.Methods The medical records of 32 inpatients with falls treated in a tertiary hospital from 2009 to 2019 were retrospectively analyzed.The fishbone diagram was used to describe the causes of falls,including environmental,nursing and management factors,as well as factors of the patient himself and their family dependents.The SHEL model was used for the management of falls from the following 4 aspects:the software aspect,the hardware aspect,the clinical environment aspect,the patient himself and others.Then,the rate of falls was compared among the hospitalized patients before intervention and 2 years after intervention.Intervention effects of fishbone diagram combined with SHEL were evaluated by using Fisher’s exact test.Results The results of Fisher’s exact test indicated that there was statistical significance in the rate of accidental falls before and after intervention,when SHEL management mode was compared with the fishbone diagram analysis combined with SHEL test(P<0.05).Conclusion Fishbone diagram analysis combined with SHEL mode management could effectively reduce the rate of falls in hospitalized patients.