血液透析上机阶段护理中断事件现况调查分析

Interruptions occurring during the starting phase of hemodialysis:a direct observational study

目的调查血液透析上机阶段护理中断事件发生现况,为针对性干预提供参考。方法观察血液透析护士在上机过程中发生的护理中断事件,包括次数、持续时间、来源及结局等。结果共观察34名血液透析护士1630例次上机操作,发生护理中断2611次,平均每个上机过程发生中断1.6次。中断事件主要来源于护士同事(46.3%)、患者或家属(42.0%);中断原因前3位为协助双人查对(45.5%)、与治疗相关的交谈(22.0%)、与治疗无关的交谈(16.4%);护士采取的应对方式为立即应对(57.2%)、多任务(20.2%)、延迟执行(18.6%)、拒绝执行(4.0%);中断事件导致消极型结局2354次(90.2%),其中43次上机错误/隐患事件(1.6%)。结论血液透析上机阶段护理中断事件发生频率高,来源多,原因复杂,且多为消极型结局,可诱发护理不良事件。应加强对护士透析工作的支持,同时加强中断事件认知培训,保障患者安全。

Objective To investigate interruptions occurring in the starting phase of hemodialysis and to provide reference for targeted interventions.Methods A direct observational study was conducted to identify the frequency,duration,sources and outcomes of interruptions occurring in the starting phase of hemodialysis.Results Thirty-four hemodialysis nurses were observed.In total,2,611 interruptions occurred in 1,630 cases of hemodialysis,with the mean number of interruptions per observation being 1.6.The main source of interruptions was team staff(46.3%),followed by patients or family members(42.0%).The top three reasons for interruptions were double-check(45.5%),treatment-related conversation(22.0%),and non-treatment-related conversation(16.4%).Nurses′actions or responses to the interruptions were engaging(57.2%),multi-tasking(20.2%),mediation(18.6%)and blocking(4.0%).A total of 2,354 interruptions(90.2%)caused negative outcomes,of which 43 were errors or potential adverse events(1.6%).Conclusion Interruption in the starting phase of hemodialysis is prevalent,multifaceted,complex and error prone.It is suggested to strengthen support and education for nurses,to ensure patient safety.