上海市医疗质量安全事件原因分析及对策研究

目的：了解本市医疗质量安全事件发生概况以及影响因素，为医疗安全防控对策的制定提供依据。方法：以整群抽样的方式，共收集2012年2938例医疗质量安全事件的相关数据进行分析。结果：医疗质量安全事件前4位高发科室为普通外科、骨科、产科及妇科。医生及医技人员中，中级职称为事件责任人主体；护士及药剂人员中，初级职称为事件责任人主体。医源性因素导致的事件发生比例位居首位（84.01%），其他还包括组织管理因素、设备器材因素以及药源性因素。结论：改进管理流程、环节及制度，加强高危科室风险防范；加强医德医风教育及业务培训，提高医务人员技能和素质。

Study on the cause and strategy for medical quality safety events in Shanghai

Objectives：To study the general situation and influencing factors of medial quality and safety events of Shanghai and to provide reference for risk control policies. Methods：Through cluster sampling, 2 938 cases of medical quality safety events in 2012 were collected. Results：The top 4 hospital departments with high risk of medical quality safety events were surgical, orthopedics, obstetrical and gynecology departments. Regarding physicians and medical technicians, the incidence of most events was attributed to medical staff with intermediate grades, while regarding nurses and pharmacists, which were attributed to medical staff with primary grades. The proportion of events attributed to medical staff （84.01%） ranked the first place. Other influencing factors included organizational and management related factors, medical devices related factors and medicine related factors. Conclusions：Improve working flow and systems to enhance risk prevention in departments with high risks. Promote medical ethics and skills education to improve the overall quality of medical staff.