【摘要】 目的探讨87例护理差错的特点及规律,以降低护理差错发生率。方法回顾性分析2001~2004年87例差错的情况,分别对护理人员结构、新到本院工作的护士首次发生差错的时间、临近换班时段的差错进行分析。结果87例护理差错涉及护理人员广泛,覆盖率为57.4%。各级人员差错发生率由高至低排序为:护师82.4%,护士78.1%,主管护师62.5%,助理护士25%。新到本院工作1年内的护士差错率达64.4%(56例)。4个护理班次换班前2h差错率为33.3%(39例)。结论护理队伍不稳定,岗前培训欠缺,工作高峰时段人员不足,责任心不强是发生差错的主要原因。建立科学的管理制度,改革排班方法,推行“双人值班制”;规范岗前培训,加强护士责任感,加强法律意识的培养,是护理安全的关键。更多还原

【Abstract】 Objective To explore the features and regulation of 87 nursing errors in order to reduce the incidence of nursing error. Methods 87 nursing errors(2001~2004) were analyzed retrospectively on manpower structure of nurses , the first time of nursing error in new nurses and the incidence of the errors in shift-transition period. Results Most nurses were involved in 87 nursing errors and accounted for 57.4% in total nurses of the hospital. The incidence of nursing error of nurses in different positions was different: senior nurse accounted for 82.4%, nurses 78.1%, supervisor nurses 62.5%, associate nurses 25%. The incidence of nursing error of nurses whose working year was less than one year was 64.4% (56 cases). The incidence of nursing errors that occurred in two hours before four shift transitions was 33.3%(39 cases). Conclusions The main reasons that caused nursing errors are unstable nurses team, lacking of training, shortage of the nurse during the heavy workload period and responsibilities negligence. Therefore, the key steps to assure the nursing safety are reforming shift arrangement, increasing nurses, enhancing nursing training and improving the awareness of responsibility and law.更多还原