根因分析法在儿科护理不良事件管理中的应用研究

摘要

Objective:To explore the causes and the link of pediatric nursing adverse events.Method:To analyze the adverse events of pediatric nursing in our hospital from January 2011 to December 2013 with the application of the root caused analysis,to explore the adverse events of type,level,age distribution, the relationship between work periods,and nursing staff capacity and system and non system cause.Result:the category from the point of view,the transfusion leakage(40.51%),medication errors(16.46%) and fall bed(15.19%) was a common.From the perspective of children aged(55.70%) of the high incidence was under 3 years of age distribution.88.61%occurred in heavy workload period during day shift and night shift nursing work.Junior,low education,low professional title nurses occurrence rate was high.The nurse’s own factors accounted for 28.96%and 71.03%for the system factors.Conclusion:The occurrence of adverse events is not entirely responsible person,more is due to system and process problems.Managers should change idea to focus on key links ,system management,nurses’ training for prevention and control of nursing adverse events.%目的：探讨儿科护理不良事件的发生原因和环节。方法：应用根因分析法，对2011年1月-2013年12月笔者所在医院儿科发生的护理不良事件进行分析，探讨不良事件发生的类型、级别、患儿年龄分布、工作时段、与护理人员能力的关系及系统和非系统原因。结果：从类别来看，以输液渗漏(40.51%)、给药错误(16.46%)和跌倒坠床(15.19%)为常见；从患儿年龄分布来看，<3岁发生率高(55.70%)；白班和夜班护理工作集中、工作量大的时段发生多(88.61%)；低年资、低学历、低职称护士发生率高；护士自身因素占28.96%，而系统因素占71.03%。结论：不良事件的发生并非完全是责任人的问题，更多的是由于系统、制度或流程上存在问题。管理上应转变理念，从组织系统上改善人员配置，重视重点环节和系统管理，护士自身应加强学习与训练，认真履行护士职责，以有效预防和控制护理不良事件的发生。