分娩过程中产妇发生护理不良事件的原因分析与对策

摘要

目的：总结分娩过程中产妇发生护理不良事件的原因及护理对策。方法：收集护理不良事件20例，进行总结和分析。结果：会阴伤口裂开6例(30.0%)，产后出血2例(10%)，医嘱审核错误3例(15.0%)，给药错误2例(10%)，产妇跌倒3例(15%)，产程观察不到位4例(20%)；护理不良事件发生在工龄1～3年护士13例(65.0%)，4～10年5例(25.0%)，＞10年2例(10.0%)；发生在主管护师1例(5%)，护师5例(25.0%)，护士14例(70.0%)。结论：低年资护理人员多是导致分娩过程中产妇发生护理不良事件的主要原因，加强岗前培训和业务学习，提高专业技能是有效预防护理不良事件的重要措施。%Objective:To summarize causes and nursing countermeasure of maternal nursing adverse events during delivery pro-cess.Methods:20 cases of nursing adverse events were selected.They were summarized and analyzed.Results:6 cases(30.0%) were perineal wound dehiscence.2 cases(10%) were postpartum hemorrhage.3 cases(15.0%) were medical examination error.2 cas-es(10%)were medication error.3 cases(15%) were maternal fall.4 cases(20%) were production process observation unfulfillment. The nursing adverse events occurred in the 1 to 3 years working years nurses with 13 cases(65.0%),4 to 10 years with 5 cas-es(25.0%),more than 10 years with 2 cases(10.0%).1 case(5%)occurred in supervisor nurse;5 cases(25.0%) occurred in nurse practitioner;14 cases(70.0%) occurred in nurse.Conclusion:Low qualification nurses is the main cause of maternal nursing adverse events during delivery process.Strengthening pre job training and business learning,improving their professional skills are the im-portant measures to effectively prevent the nursing adverse events.