CAJ | 학술논문

目的：分析护理不良事件发生的原因与特点，探讨如何采取持续有效的改进措施，减少不良事件的发生。方法回顾性分析综合内科病房2011年6月～2012年12月发生的19例护理不良事件，对不良事件发生原因及逐年发生情况进行分析对比。结果2011年发生7例护理不良事件，其中违反护理核心制度6例、针刺伤1例；2012年发生12例护理不良事件，其中违反护理核心制度3例、针刺伤2例、非计划性拔管3例、跌倒2例、压疮2例。结论护理管理者应根据护理不良事件的原因和特点，不断制定、完善整改措施，以达到减少不良事件的发生，提高护理安全的目的。
목적：분석호리불량사건발생적원인여특점，탐토여하채취지속유효적개진조시，감소불량사건적발생。방법회고성분석종합내과병방2011년6월～2012년12월발생적19례호리불량사건，대불량사건발생원인급축년발생정황진행분석대비。결과2011년발생7례호리불량사건，기중위반호리핵심제도6례、침자상1례；2012년발생12례호리불량사건，기중위반호리핵심제도3례、침자상2례、비계화성발관3례、질도2례、압창2례。결론호리관리자응근거호리불량사건적원인화특점，불단제정、완선정개조시，이체도감소불량사건적발생，제고호리안전적목적。
Objective To analyze the reasons and characteristics of nursing adverse events, and discuss how to take measures to improve continuously and effectively, reduce the occurrence of adverse events. Methods 19 nursing adverse events were retrospectively analyzed occurred in comprehensive Department of internal medicine ward from June 2011 to December 2012, adverse events cause were comparatively analyzed. Results 7 cases occurred nursing adverse events in 2011, including 6 cases with violation of nursing core regulations,1 case with needle stick injuries;12 cases occurred nursing adverse events in 2012, including 3 cases with violation of nursing core regulations, 2 cases with needle stick injuries, 3 cases with non planned decannulation, 2 cases with falling,2 cases with ulcer. Conclusion Nursing administrators should be based on the causes and characteristics of nursing adverse events, and continuously develop, perfect reform measures, in order to reduce the occurrence of adverse events, and improve the nursing safety.