医院化疗相关护理不良事件的归因分析

目的：了解医院化疗相关护理不良事件发生环节，分析其原因，为化疗相关护理不良事件的预防和早发现、早处理、制定更为合理全面的化疗护理管理策略提供依据。方法对某两家三级甲等医院4年上报的化疗相关护理不良事件共40起进行回顾性归因分析。结果40起化疗相关护理不良事件出现最多的类别为给药错误，占27．50％；所有发生环节中，外周静脉化疗药物渗漏表现最为突出，占20．00％；查对不严是化疗相关护理不良事件发生的主要内因，占15．69％；患者的身体状况不佳为主要外因，占7．84％。同时，患者及家属的参与在很大程度上实现了不良事件的早发现。化疗相关护理不良事件发现阶段分布为化疗前10．00％，化疗中35．00％，化疗后55．00％。40起化疗相关护理不良事件中，护士发现占56．67％，患者及家属发现占43．33％。结论化疗相关护理不良事件的归因分析显示，护士的职业素质和医院的管理制度都有可待提高的空间，新型的、系统的化疗安全管理策略值得进一步研究。

Attribution analysis of hospital originating segments of nursing adverse events about chemotherapy

Objective To learn the links of hospital originating segments of nursing adverse events about chemotherapy and analyze the causes, in order to prevent, early detect and treat, and to provide basis for developing more rational strategies.Methods Totals of 40 cases of adverse events reported in two upper first-class hospitals were retrospectively analyzed.Results The most frequent type of the 40 nursing adverse events about chemotherapy were medication errors, accounting for 27.50%.Peripheral venous leakage of chemotherapy drugs was the most prominent of all the originating segments, accounting for 20.00%.Check lax was the main internal cause of chemotherapy adverse events, accounting for 15.69%.Patients’ poor physical condition was the main external factor, accounting for 7.84%.Meanwhile, patients and their families’ participation could greatly help to achieve early detection of nursing adverse events about chemotherapy.10.00%of nursing adverse events were detected before chemotherapy, 35.00% of nursing adverse events were detected during chemotherapy, and 55.00%of nursing adverse events were detected after chemotherapy.Within the 40 nursing adverse events, 56.76%of the events were detected by nurses and 43.33%of the events were detected by the patients or their families.Conclusions The analysis of the nursing adverse events about chemotherapy shows that nurses’ professional ability and hospital management system need to be improved.A new systematic chemotherapy security management strategies are worthy for further study.