CAJ | 학술논문

　　目的分析精神科护理不良事件发生的原因，为患者安全和风险管理提供依据。方法对某三级甲等精神病专科医院2010年～2012年上报的89例护理不良事件进行回顾性分析。结果精神科护理不良事件排在前三位的是攻击行为（26.9%），跌倒、坠床（21.3%），走失（16.9%）；发生原因排前三位的是风险意识差（37.1%）护士责任心不强（16.9%）及规章制度未落实（14.6%）。结论精神科护理服务有其特殊性，护理不良事件的发生，既有人为因素，又有系统因素。运用根本原因分析法，综合考虑这两方面因素，对护理不良事件进行分析和处理，才能营造健康的护理安全文化环境。
　　목적분석정신과호리불량사건발생적원인，위환자안전화풍험관리제공의거。방법대모삼급갑등정신병전과의원2010년～2012년상보적89례호리불량사건진행회고성분석。결과정신과호리불량사건배재전삼위적시공격행위（26.9%），질도、추상（21.3%），주실（16.9%）；발생원인배전삼위적시풍험의식차（37.1%）호사책임심불강（16.9%）급규장제도미락실（14.6%）。결론정신과호리복무유기특수성，호리불량사건적발생，기유인위인소，우유계통인소。운용근본원인분석법，종합고필저량방면인소，대호리불량사건진행분석화처리，재능영조건강적호리안전문화배경。
Objective To analyze the causes of psychiatric nursing adverse events, and provide the basis for the safety and risk management of patients. Methods A retrospective analysis was made on 2010 to a three level of first-class psychiatric hospital reported in 2012 89 cases of nursing adverse events. Results Psychiatric nursing adverse events in the top three are aggressive behavior (26.9%), falling down, falling out of bed (21.3%), (16.9%); lost causes ranked the top three is the risk consciousness difference (37.1%) nurses responsibility heart is not strong (16.9%) and the regulations do not implement (14.6%). Conclusion Psychiatric nursing services has its particularity, the nursing adverse events, both human factors and system factors. Using root cause analysis method, considering these two factors, analysis and processing of the nursing adverse events, to build safety culture in nursing and healthy environment.