210例护理不良事件原因分析及对策

摘要

Objective To take preventive measures to reduce the occurrence by analyzing the causes and characteristics of adverse nursing events.Methods A total of 210 cases of adverse nursing events reported from 2008 to 2010 in a level 3 hospital were retrospectively studied.Causes and characteristics were analyzed.Results Majority of the adverse nursing events (54.76％) came from nurses with less than 5-year working experience.Among those,nurses with lower professional ranking had more adverse nursing events.First four major categories of the adverse nursing events were wrong medication (34.8％ ),unplanned extubation ( 18.6％ ),fall/drop from bed ( 15.2％ ),and pressure ulcer ( 14.8％ ).The main causes of the adverse events included insufficient assessment (42.4％),error in checking ( 29.0％ ),unstandardized operating ( 15.2％ ),and lack of education ( 8.1％ ).Wrong medication,unplanned extubation and fall from the bed occurred at significant different period of time during the day (08:00 ～ 11:00 and 14:00 ～ 17:00 for wrong medication; 1:00 ～ 5:00 for unplanned extubation and 18:00 ～ 22:00 for fall from the bed,x2 =25.054,17.833,20.875,respectively; P ＜ 0.01 ).Pressure ulcers occurred throughout the day.There was no significant difference ( P ＞ 0.05 ).Conclusions The adverse nursing events should be paid attention by nursing managers.Future occurring of the similar adverse nursing events should be prevented by setting up the awareness of safety,reasonable distribution of the human resource,strengthening the training of the key people and the management of the key period of the day,researching the sources of the events,and making effective measures to create a safe working environment.%目的 通过对210例护理不良事件进行分析,查找不良事件发生的原因和特点,针对其采取防范措施,以期减少不良事件的发生.方法 对某三级医院2008-2010年上报的210例护理不良事件进行回顾性研究,分析不良事件发生的原因及特点.结果 工作5年内的护士不良事件发生率最高,占54.76％,低职称的护士不良事件发生率高于高职称护士;不良事件发生的类别居前4位的依次为给药错误,占34.8％;非计划性拔管,占18.6％;跌倒/坠床,占15.2％;压疮,占14.8％.不良事件发生的主要原因居前4位的依次为评估不足,占42.4％;查对错误,占29.0％;未执行操作规程,占15.2％;宣教不到位,占8.1％;给药错误、非计划性拔管、跌倒/坠床的发生在一天内不同时间段发生情况,差异有统计学意义(x2分别为25.054,17.833,20.875;P ＜0.01),其中给药错误主要发生在8:00～11:00、14:00～17:00,非计划性拔管主要发生在1:00 ～5:00,跌倒/坠床主要发生在18:00～22:00;压疮的发生在一天内不同时间段发生情况,差异无统计学意义(P＞0.05).结论 护理管理者要重视对不良事件的分析,树立护理人员的安全意识,合理配备人力,加强重点人群的培训,加强重点时间段的管理,查找根源,制定有效措施,营造安全的工作环境,全面防范护理不良事件的发生.