中国实用护理杂志
中國實用護理雜誌
중국실용호리잡지
CHINESE JOURNAL OF PRACTICAL NURSING
2015年
13期
977-979
,共3页
住院病人%老年人%意外跌倒%根本原因分析
住院病人%老年人%意外跌倒%根本原因分析
주원병인%노년인%의외질도%근본원인분석
Inpatients%Aged%Accidental falls%Root cause analysis
目的 对住院老年患者的跌倒事件进行根本原因分析,以期为该护理不良事件的防范提供理论依据.方法 对62例老年住院患者发生跌倒的护理不良事件采用根本原因分析(root causeanalysis,RCA,简称根因分析)法查找原因.结果 住院老年患者跌倒因素涉及身体、疾病、药物、心理、环境等方面,原因在于老年人身体机能减退、外在环境危险因素、健康教育不到位、老人照护保障系统缺乏等,其中疾病因素中的脑梗死所占比例最高[22.58％(14/62)],其次为老年性痴呆[20.97％(13/62)];药物因素中的抗精神失常药、环境因素中的床脚轮未制动、地灯未使用所占比例最低,均为3.23％(2/62).结论 通过RCA法可找出住院老年患者跌倒的原因,达到改善流程、事先防范的目的.
目的 對住院老年患者的跌倒事件進行根本原因分析,以期為該護理不良事件的防範提供理論依據.方法 對62例老年住院患者髮生跌倒的護理不良事件採用根本原因分析(root causeanalysis,RCA,簡稱根因分析)法查找原因.結果 住院老年患者跌倒因素涉及身體、疾病、藥物、心理、環境等方麵,原因在于老年人身體機能減退、外在環境危險因素、健康教育不到位、老人照護保障繫統缺乏等,其中疾病因素中的腦梗死所佔比例最高[22.58％(14/62)],其次為老年性癡呆[20.97％(13/62)];藥物因素中的抗精神失常藥、環境因素中的床腳輪未製動、地燈未使用所佔比例最低,均為3.23％(2/62).結論 通過RCA法可找齣住院老年患者跌倒的原因,達到改善流程、事先防範的目的.
목적 대주원노년환자적질도사건진행근본원인분석,이기위해호리불량사건적방범제공이론의거.방법 대62례노년주원환자발생질도적호리불량사건채용근본원인분석(root causeanalysis,RCA,간칭근인분석)법사조원인.결과 주원노년환자질도인소섭급신체、질병、약물、심리、배경등방면,원인재우노년인신체궤능감퇴、외재배경위험인소、건강교육불도위、노인조호보장계통결핍등,기중질병인소중적뇌경사소점비례최고[22.58％(14/62)],기차위노년성치태[20.97％(13/62)];약물인소중적항정신실상약、배경인소중적상각륜미제동、지등미사용소점비례최저,균위3.23％(2/62).결론 통과RCA법가조출주원노년환자질도적원인,체도개선류정、사선방범적목적.
Objective To analyze the falling events using root cause analysis (RCA) in hospitalized elderly patients in order to supply theoretic reference for precaution of falling events.Methods RCA method was used to analyze the root cause against 62 cases of nursing adverse events of hospitalized elderly patients' falling.Results Hospitalized elderly patients' falling is related to various factors such as body,disease,medicine,psychology,environment and so on.The root cause lied in the elderly' physical function decline,risk factors of external environment,unfulfilled health education,and lack of the care and support system for the elderly,among which cerebral infarction belonging to the disease factors accounted for 22.58％ (14/62),which was the highest;next was senile dementia [20.97％ (13/62)].The rates of agents against psychiatric disorders belonging to the medicine factors and no braking of bed pulley and no use of blister light belonging to environmental factors were the lowest,all were 3.23％ (2/62).Conclusions The falling reason of elderly inpatients can be found out by RCA in order to attain the purpose of improving procedure and prevention in advance.
