CAJ | 학술논문

目的：通过根本原因分析法（RCA）分析某二级综合医院的护理不良事件，进行原因分析并制定相应对策。方法对2013年某二级综合医院上报医院的49例护理不良事件汇总行RCA分析。结果护理不良事件前四位分别是坠床、跌倒、烫伤等意外事件，非计划性拔管，输液不良反应，药物外渗；发生不良事件相对较多的科室为普外科、新生儿科、重症监护室、产科；5年以下低年资护士发生不良事件占66.4%。结论应加强年轻护士的培训，做好高危病人的评估，加强管路管理，减少意外事件的发生，以提升护理安全。
목적：통과근본원인분석법（RCA）분석모이급종합의원적호리불량사건，진행원인분석병제정상응대책。방법대2013년모이급종합의원상보의원적49례호리불량사건회총행RCA분석。결과호리불량사건전사위분별시추상、질도、탕상등의외사건，비계화성발관，수액불량반응，약물외삼；발생불량사건상대교다적과실위보외과、신생인과、중증감호실、산과；5년이하저년자호사발생불량사건점66.4%。결론응가강년경호사적배훈，주호고위병인적평고，가강관로관리，감소의외사건적발생，이제승호리안전。
Objective To analyze the root cause of nursing adverse events and formulate the corresponding measures. Methods The status of 49 nursing adverse events were analyzed retrospectively, the primary causes were traced to enable control measures to be devised. Results Accidents which including bed fall, tumble and empyrosis, unplanned extubation, infusion reaction, extravasation of drugs were the top four rankings of nursing adverse events. In the departments including general surgery, Neonatology, ICU, Obstetric, the incidence of adverse events was higer than that of other departments. The nurses with less than 5 years of service were predominant in the nurse responsible for the adverse events, accounting for 66.4%. Conclusion It shoud be strengthened to train the junior nurse and to manage variety catheters, the risk assessment of a high-risk group should be carried out to reduce the occurrence of accidents and to ensure the patients safety.