【摘要】 目的通过对护理不良事件发生原因进行分析,提出预防措施,降低非正常护理意外事件。方法对某三级医院2005-2012年上报护理不良事件进行分类,运用追踪法、帕累托法确定不良事件发生的主要原因。结果导致574起不良事件发生的主要原因为制度执行不力、护理人员专业知识缺乏、医护沟通问题、作业流程不良,累积比例达77.1%,需要进行重点改进。结论转变质量管理理念,优化护理流程,从系统上进行防呆;引入"安灯"系统,倡导人人参与质量管理;推行"SBAR"沟通模式和早期预警评分系统等,有效降低不良事件的发生。更多还原

【Abstract】 Objective It aims to come up with preventive measures against unexpected events resulting from abnormal nursing by analyzing the causes of adverse events in nursing. Methods A total of 574 nursing adverse events reported from 2005 to 2012 in a tertiary hospital were classified and analyzed by tracing method and Pareto principle. Results The adverse events mainly resulted from inadequate enforcement of regime, nursing professionals lack of expertise, ineffective communication between nurses and doctors, and poor nursing flow, which accounted for 77.1%, and therefore called for significant improvement. Conclusion The idea of quality management should be transformed to optimize nursing flow for systematically fool-proof enforcement. An Andon system should be introduced for everyone to join in quality management. The SBAR and EWS systems should be adopted to effectively reduce adverse effects.更多还原