血液透析室护理不良事件原因分析及防范对策

目的:探讨血液透析室出现的不良事件相关内容,并制定防范对策。方法:将2006年10月至2011年10月血液透析室发生的不良事件做回归性分析,责任心不强、查对制度落实不到位、技术操作不熟练、不熟悉机器操作流程、病情观察不仔细、无菌观念欠缺、健康宣教不到位、语言沟通不良、自我保护及风险意识淡漠进行分析。结果:血液透析室出现不良事件的原因从高到低依次为:责任心不强、查对制度落实不到位、自我保护及风险意识淡漠、病情观察不仔细、技术操作不熟练、无菌观念欠缺、语言沟通不良、健康教育不到位、不熟悉机器操作流程。结论:加强血液透析室安全管理、制定合理工作流程、提高护理人员的业务水平和综合素质,实施必要的惩罚和非惩罚相结合不良事件报告制度,能有效控制血透室不良事件发生,提高护理工作质量,避免护患纠纷的发生。

Objective:Room of hemodialysis-related adverse events occur content,and to develop preventive measures.Method:The October 2006 to October 2011 occurred in hemodialysis room to do regression analysis of adverse events,sense of duty,check the implementation of systems in place,technical operations unskilled,are not familiar with the machine operating process,the condition not carefully observed,lack of sterile concept,health education is not in place,bad language,self-protection,and risk conscious indifference analysis.Result:Hemodialysis room because of adverse events occur in the order of:sense of duty,check the implementation of systems in place,the risk of self-protection and sense of apathy,not carefully observed conditions,technical operations unskilled,lack of sterile concept,language poor communication,health education is not in place,are not familiar with the machine operating process.Conclusion:Strengthen the management of hemodialysis room safe,work to develop a reasonable process to improve the level of nursing services and the overall quality,the implementation of the necessary combination of punishment and non-punitive adverse event reporting system,can effectively control the occurrence of adverse events in hemodialysis room to improve the quality of care to avoid the occurrence of nursing disputes.