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护理不良事件分析与对策研究

Nursing Adverse Events Analysis and Countermeasure Research

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目的 分析某三级综合医院护理不良事件,制订改进措施.方法 收集并分析2023年1月1日-12月31日某院279例护理不良事件的级别、类型、患者年龄、发生时间、科室分布以及当事护理人员工作年限和职称等情况.结果 以Ⅲ级和Ⅳ级不良事件为主(91.76%),多发于41岁~<81岁中老年人(63.80%),当事护士工作年限以1 a~<6 a为主(34.05%),多发于工作日(74.19%)和早班班次(54.12%).非计划拔管(27.96%)、跌倒/坠床(15.05%)、给药错误(10.75%)占比较高,主要分布在消化内科(8.60%)、急诊科(8.24%)、ICU(7.53%),消化内科、ICU主要是非计划拔管,急诊科主要是检验相关事件.结论 加强护理不良事件规范化管理,建立护理不良事件管理系统,运用质量管理工具持续改进护理质量.
Objective To analyze the nursing adverse events in a tertiary general hospital and formulate improve-ment measures. Methods The levels,types,patient age,occurrence time,department distribution,working years and professional titles of nursing staff were collected and analyzed for 279 nursing adverse events in a hospital from Janu-ary 1 to December 31,2023. Results The main adverse events were grade Ⅲ and Ⅳ(91.76%),mostly in the middle-aged and elderly people aged 41~<81 years (63.80%). The working years of the nurses were mainly 1 a~<6 a (34.05%),mostly on the working day (74.19%) and early shift (54.12%). Unplanned extubation (27.96%),fall/fall bed (15.05%),medication error (10.75%) accounted for a relatively high proportion. The patients were mainly dis-tributed in the department of gastroenterology (8.60%),emergency department (8.24%) and ICU (7.53%). Adverse events occurred in the department of gastroenterology,ICU were mainly unplanned extubation,in the emergency depart-ment was mainly test related events. Conclusion It is suggested that hospital should strengthen the standardized management of nursing adverse events,establish a nursing adverse event management system,and use quality manage-ment tools to continuously improve the quality of care.

Nursing Adverse EventsNursing QualityPatient Safety

卢琪琪、许苹、蔡雅荣、黄书琳

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石狮市总医院 福建 泉州 362700

海军军医大学卫生勤务学系卫生事业管理学教研室 上海 200433

护理不良事件 护理质量 患者安全

2024

中国卫生质量管理
中国医院协会,陕西省人民医院

中国卫生质量管理

CSTPCD
影响因子:1.091
ISSN:1006-7515
年,卷(期):2024.31(11)