CAJ | 학술논문

目的通过分析不良事件发生的原因及特点,探讨如何避免不良事件的发生,为提高患者安全管理,制订相应防范措施减少不良事件提供依据.方法回顾某三级甲等综合医院2008年度护理系统上报的335起不良事件,对不良事件分类、发生原因、时间特点及护患比例进行研究.结果①护理不良事件前三位分别是管路滑脱、压疮、跌倒.②主要原因分别是评估不足和沟通不良.③护士资历与不良事件的发生有关.④资历较低的护士在评估及沟通方面存在显著不足.⑤一周之内以周三、周四为不良事件发生的高峰,而在一天之内,以8:00、15:00和22:00为不良事件发生的三大高峰.结论医院要从组织系统上改善人员配置并建立组织安全文化,对护理人员进行相关培训,提高护士整体的风险意识水平和综合素质是降低不良事件发生率的根本途径.科室改革护理人员的排班模式,按照患者的需求进行弹性排班是降低不良事件发生率的有效途径.
목적 통과분석불량사건발생적원인급특점,탐토여하피면불량사건적발생,위제고환자안전관리,제정상응방범조시감소불량사건제공의거.방법 회고모삼급갑등종합의원2008년도호리계통상보적335기불량사건,대불량사건분류、발생원인、시간특점급호환비례진행연구.결과①호리불량사건전삼위분별시관로활탈、압창、질도.②주요원인분별시평고불족화구통불량.③호사자력여불량사건적발생유관.④자력교저적호사재평고급구통방면존재현저불족.⑤일주지내이주삼、주사위불량사건발생적고봉,이재일천지내,이8:00、15:00화22:00위불량사건발생적삼대고봉.결론 의원요종조직계통상개선인원배치병건립조직안전문화,대호리인원진행상관배훈,제고호사정체적풍험의식수평화종합소질시강저불량사건발생솔적근본도경.과실개혁호리인원적배반모식,안조환자적수구진행탄성배반시강저불량사건발생솔적유효도경.
Objective To analyze the causes and feature of nursing adverse events in order to explore the strategies to avoid adverse events and enhance patient safety management.Methods A total of 335 cases of nursing adverse events reported in 2008 in a Ⅲ-A hospital were retrospectively analyzed,including the categorization,causes,time distribution,and nurse-patient ratio.Results The top three kinds of nursing adverse events were tube emersion(n= 185),pressure sores(n=63),and falls(n=33).The main causes were inadequate assessment(n=86)and ineffective communication(n=73).Most adverse events happened on junior nurses who had difficulties in patients assessment and communication.More nursing adverse events occured on Wednesday,Thursday,and weekends during a week,at 8am,3pm,and 10pm during a day.Conclusion The fundamental way of reducing the incidence of adverse events is to improve staff arrangement,build up a safety culture,strengthen nurse training to enhance their risk awareness and general quality.Moreover,it would be effective to reform the scheduling model based on patients needs.