SHEL模式在护理不良事件原因分析中的应用

目的分析护理不良事件的发生原因,为患者护理安全管理提供依据。方法应用SHEL模式对2013年1月至12月全院发生并主动上报至护理部的131例护理不良事件进行回顾性分析。结果 131例护理不良事件中,与护士业务素质和能力有关的共106例,占80.92%;与护理工作场所及设施有关的15例,占11.45%;与临床环境有关的45例,占34.35%;与当事人及他人有关的57例,占43.51%。结论根据不良事件发生原因制订管理对策,加强培训,提高护士业务素质和能力、完善硬件建设和工作流程,从而有效防范护理不良事件的发生。

The application of SHEL model in the cause analysis of nursing adverse events

Objective To analyze the causes of nursing adverse events, so as to provide basis for patients＇safety management. Methods Totally, 131 cases of adverse events in nursing from January to December in 2013 were retrospectively analyzed by applying SHEL model. Results In 131 cases of adverse events, 106 cases were related with nurses＇ quality and capacity, accounting for 80.92%, 15 cases were related with workplace and facilities, accounting for 11.45%. 45 cases were related with clinical environment, accounting for 34.35% and 57 cases were related with the parties and others concerned, accounting for 43.5 1%. Conclusion It is suggested to implement management measures based on the reasons of adverse events, train nurses to improve their professional quality and capacity, enhance patient assessment and safety education, improve hardware construction, optimize work procedure, so as to prevent the occurrence of ad- verse events in nursing effectively.