护理不良事件分析与对策研究

Nursing Adverse Events Analysis and Countermeasure Research

目的分析某三级综合医院护理不良事件,制订改进措施。方法收集并分析2023年1月1日-12月31日某院279例护理不良事件的级别、类型、患者年龄、发生时间、科室分布以及当事护理人员工作年限和职称等情况。结果以Ⅲ级和Ⅳ级不良事件为主(91.76%),多发于41岁~<81岁中老年人(63.80%),当事护士工作年限以1 a~<6 a为主(34.05%),多发于工作日(74.19%)和早班班次(54.12%)。非计划拔管(27.96%)、跌倒/坠床(15.05%)、给药错误(10.75%)占比较高,主要分布在消化内科(8.60%)、急诊科(8.24%)、ICU(7.53%),消化内科、ICU主要是非计划拔管,急诊科主要是检验相关事件。结论加强护理不良事件规范化管理,建立护理不良事件管理系统,运用质量管理工具持续改进护理质量。

Objective To analyze the nursing adverse events in a tertiary general hospital and formulate improvement measures.Methods The levels,types,patient age,occurrence time,department distribution,working years and professional titles of nursing staff were collected and analyzed for 279 nursing adverse events in a hospital from January 1 to December 31,2023.Results The main adverse events were grade III andⅣ(91.76%),mostly in the middle-aged and elderly people aged 41~<81 years(63.80%).The working years of the nurses were mainly 1 a~<6 a(34.05%),mostly on the working day(74.19%)and early shift(54.12%).Unplanned extubation(27.96%),fall/fall bed(15.05%),medication error(10.75%)accounted for a relatively high proportion.The patients were mainly distributed in the department of gastroenterology(8.60%),emergency department(8.24%)and ICU(7.53%).Adverse events occurred in the department of gastroenterology,ICU were mainly unplanned extubation,in the emergency department was mainly test related events.Conclusion It is suggested that hospital should strengthen the standardized management of nursing adverse events,establish a nursing adverse event management system,and use quality management tools to continuously improve the quality of care.