【摘要】 目的通过分析引起护理不良事件发生的原因及特点,探讨如何减少或避免不良事件的发生,提高患者安全。方法通过对某院2015年565起非惩罚性自愿呈报的护理不良事件进行统计,分析不良事件的主要原因、不良事件与护士年资、发生时间的关系。结果前4位护理不良事件分别是坠床跌倒(20.5%)、导管滑脱18.9%、院内压疮(17.7%)、给药错误(15.2%)。主要原因是缺少评估与预见性(18.1%),交接不到位(15.2%)。夜间1:00-7:00为导管滑脱及坠床跌倒的高发时段,分别占45.8%、62.9%。日间8:00-12:00为给药错误的高峰期,占46.5%。低职称护士不良事件发生率显著高于高职称护士(P<0.05)。结论医院要从组织系统上改善人员配置及进行沟通、安全等方面的教育,提高护士风险意识和评估预见能力以降低护理不良事件的发生率。更多还原

【Abstract】 Objective To analyze the causes and characteristics of nursing adverse events in order to reduce the incidence rate and enhance patient safety. Methods A total of 565 nursing adverse events were analyzed through non-punitive voluntary reporting system in a hospital in 2015, which included the main causes, the relationship between nursing adverse events and nurse work experience as well as time of incidence. Results The top four nursing adverse events were falls(20.5%), tube emersion(18.9%), hospital pressure ulcers(17.7%), and medication error(15.2%). The main causes were lack of evaluation and predictability(18.1%) and ineffective communication(15.2%). Incidence rate of falls(62.9%) and tube emersions(45.8%) from 1:00 AM to 7:00 AM were higher than that in other period. The peak of incidence of medication error(46.5%) was from 8:00 AM to 12:00 AM. Nurses with lower professional title experienced more nursing adverse events than nurses with higher professional title(P<0.05). Conclusion Hospital administrators should improve human resource management and organize training of communication and safety to enhance nurses’ risk awareness, ability of evaluation and prediction so as to reduce the incidence rate of adverse events.更多还原