CAJ | 학술논문

目的探讨提高患者安全管理、降低护理不良事件发生率的方法。方法回顾分析重庆市第三人民医院2012年上报的41例院内护理不良事件的原因与特点，对发生不良事件的患者性别及年龄、时间地点及不良事件的结局和分类进行统计学分析。结果80～89岁和50～59岁患者不良事件发生率最高（53．6％）；护理不良事件分类中，发生率最高的为跌倒、压疮和给药错误；不良事件上报率最高的科室为老年科、神内科、重症监护病房（ICU ）；院内不良事件发生的主要时间段为上午（08：00～12：00），夜间（00：00～08：00）和晚间（18：00～00：00）；损伤结局中，跌倒是造成患者重度损伤的主要原因。结论医院应完善管理制度、明确岗位职责，合理排班和配置各项资源，提高护理人员的风险意识和护理水平，是减少护理不良事件的根本途径。
목적탐토제고환자안전관리、강저호리불량사건발생솔적방법。방법회고분석중경시제삼인민의원2012년상보적41례원내호리불량사건적원인여특점，대발생불량사건적환자성별급년령、시간지점급불량사건적결국화분류진행통계학분석。결과80～89세화50～59세환자불량사건발생솔최고（53．6％）；호리불량사건분류중，발생솔최고적위질도、압창화급약착오；불량사건상보솔최고적과실위노년과、신내과、중증감호병방（ICU ）；원내불량사건발생적주요시간단위상오（08：00～12：00），야간（00：00～08：00）화만간（18：00～00：00）；손상결국중，질도시조성환자중도손상적주요원인。결론의원응완선관리제도、명학강위직책，합리배반화배치각항자원，제고호리인원적풍험의식화호리수평，시감소호리불량사건적근본도경。
Objective To analyze the causes and characters of adverse events reported through Intra-hospital Reporting System (IHRS) .Methods A retrospective study was conducted to analyze the adverse events collected through IHRS and statistical analysis was used to analyze items ,including patients'age and sex ,time distribution and location ,classification and outcome of the adverse events .Results Incidence in old patients was the highest (55 .6% ) .The top three kinds of nursing adverse events were fall ,pressure sores and medication errors .Department of Geriatrics ,Neurology and ICU had the top three adverse event report ratio .Adverse events happened more fre-quently in daytime (8 :00 am-12 :00 am) ,nighttime (0 :00 am-8 :00 am) and evening (6 :00 pm-0 :00 am) .Fall was the main reason causing severe injury in patients .Conclusion The fundamental way of reducing the incidence of adverse events could be the improvement of management system ,the definition of responsibilities ,the arrangement of re-sources and the nurse training to enhance risk awareness and general quality .