应用国际医疗认证联合委员会评审标准分析90起护理不良事件的原因

目的应用国际医疗认证联合委员会评审标准,分析90起护理不良事件发生的类别、原因和时间特点,以制定有效的预防措施,减少护理不良事件的发生。方法依据国际医疗认证联合委员会(Joint Commission International,JCI)对医院安全与规范化管理的相关要求,对2010年1月—2011年9月上报的90起护理不良事件进行回顾分析。结果护理不良事件主要发生在药物管理和使用、员工资格和教育方面;排前3位的不良事件类别依次是输液类、药物类和标本类;交接班时间段是不良事件高发的时间段;低年资护士是护理不良事件的高风险人群。结论需依据JCI相关要求,加强员工的在职教育和培训;完善临床药物派送系统和加强查对制度的落实;尽快改变排班模式,根据需求弹性排班,尽量减少护士交接班次数,并规范护士交接班流程;完善科室常见病种的护理常规及操作指引,尽量从系统的根源避免护理不良事件的发生,提升医院管理品质,推进医院向国际化市场发展。

Application of Joint Commission International Standards in Nursing Adverse Events

Objective To analyze the causes and features of nursing adverse events and to explore effective preventive measures for adverse events.Methods A total of 90 nursing adverse events reported from January 2010 to September 2011 were retrospectively analyzed in accordance with the standards of Joint Commission International(JCI).Results Most adverse events involved medication management and usage,staff qualifications and education and the top three kinds of nursing adverse events were intravenous mistaking,medicine mistaking and specimen error.There were lots of adverse events happened during handover and junior nurses tended to make these mistaking most.Conclusion Analysis of nursing adverse events revealed the root cause of the incident.It can provide evidence for perfect medical system,and ensure the safety of patients and medical staff as well.