CAJ | 학술논문

目的采用根原因分析法对我院3年来护理不良事件进行分析，以便找出根本原因，确立防范措施。方法成立护理风险管理委员会，对委员会成员进行根原因分析法相关知识的培训，应用该方法对2010年1月-2012年12月三年来我院发生的57起护理不良事件进行分析，找出并确立根原因。结果通过采用该方法对3年来发生的护理不良事件进行分析，57起中31起是由系统原因造成的，占总数的54.4%；26起是由个人原因造成的，占总数的45.6%。结论应用根原因分析法对护理不良事件进行分析，制订相应的改进计划并落实，能有效规避类似不良事件的发生，从而确保护理安全。
목적채용근원인분석법대아원3년래호리불량사건진행분석，이편조출근본원인，학립방범조시。방법성립호리풍험관리위원회，대위원회성원진행근원인분석법상관지식적배훈，응용해방법대2010년1월-2012년12월삼년래아원발생적57기호리불량사건진행분석，조출병학립근원인。결과통과채용해방법대3년래발생적호리불량사건진행분석，57기중31기시유계통원인조성적，점총수적54.4%；26기시유개인원인조성적，점총수적45.6%。결론응용근원인분석법대호리불량사건진행분석，제정상응적개진계화병락실，능유효규피유사불량사건적발생，종이학보호리안전。
Objective To conduct root cause analysis on nursing adverse events of our hospital in the past 3 years to identify root causes and develop preventive measures. Methods The hospital set up a nursing risk management committee and provided training on root cause analysis among committee members to analyze and identify root causes of 57 cases of nursing adverse events that happened in our hospital from January 2010 to December 2012. Results Root cause analysis on nursing adverse events of the past 3 years indicated that 54.4%(31) of 57 cases were caused by the system while 45.6%(26) were caused by medical workers. Conclusion Development and implementation of improvement plan based on root cause analysis of nursing adverse events is effective in preventing occurrence of similar adverse events and ensuring nursing safety.