64例护理不良事件分析及对策

目的：通过分析护理不良事件发生的原因及特点,探讨避免不良事件发生的措施,为提高患者安全管理,制定相应防范措施,减少不良事件提供依据。方法：回顾性分析普外科2010年12月-2011年11月发生的64例护理不良事件,对不良事件分类、发生原因、时间特点及与不同工作年限护士的关系进行研究。结果：护理不良事件前三位分别是管路滑脱、给药错误、漏执行医嘱;主要原因分别是查对制度执行不严、安全管理不到位、临床带教工作不严谨。1周之内周三、周四为不良事件发生的高峰,而在1d之内,A班和N班为不良事件发生的高峰;护士资历与不良事件的发生有关。结论：在临床护理工作中要鼓励护士加强责任心,严格执行各项核心制度,减少护理不良事件的发生;护理管理者要在质量管理与持续改进中,进行原因分析并制定防范措施,加强护理工作安全管理,提升护理服务质量和水平。

Nursing Care of 64 Cases of Adverse Event Analysis and Countermeasures

Objective：To analyze the causes of adverse events and characteristics, to explore how to avoid the occurrence of adverse events, toimprove patient safety management, development of appropriate preventive measures to reduce adverse events to provide a basis.Method：Retrospective analysis of general surgery from December 2010 to November 2011 occurred in 64 cases care adverse events, adverse event classification, causes, time characteristics andwithdierentwrkexperiencetstudythereatinshipfnurses.Resut：Careadverseventswerethetpthreeinessip administration errors, omissions, implementation of living willa;Checking system were mainly due to lax implementation of safety management in place, clinical teaching work is not rigorous. Within a week Wednesday, Thursday is the peak of adverse events, and in one day, to Class A and N class is the peak of adverse events;Nurse qualifications and the occurrence of adverse events.Conclusion：In clinical care, we should encourage nurses to enhance accountability, strict implementation of the core system, reducing the occurrence of adverse events care;care managers in quality management and continuous improvement in the cause analysis and to develop preventive measures to enhance care security management, improve service quality and level of care.