非惩罚性护理不良事件报告制度在手术室的应用

目的探讨非惩罚性护理不良事件报告制度在手术室的应用效果。方法成立不良事件分析小组,在手术室建立非惩罚性护理不良事件报告制度,对出现护理不良事件采取不公开、非惩罚的处理原则,分析发生护理不良事件的根本原因,提出改进意见和预防措施,不断修改完善护理工作流程及管理制度。结果实施后护理不良事件上报率由14.04%提高到85.71%(P<0.01);护士对不良事件的认知及上报的态度显著改善(P<0.05,P<0.01)。结论在手术室实施非惩罚性护理不良事件报告制度能明显改善护士对护理不良事件的认知及上报态度,有助于找到不良事件发生的原因,从根本上杜绝同类不良事件的发生,有利于预防和避免严重不良事件的发生。

Implementation of a non-punitive,adverse nursing event reporting system in the operating room

Objective To explore the implementation and effects of a non-punitive,adverse nursing event reporting system in the operating room.Methods A non-punitive,adverse nursing event reporting system was initiated by an adverse nursing event analyzing group.The program had non-public and non-punitive principles;the causes of adverse events were analyzed; corrective and preventive measure was taken;improvement of working process and administration system was put forward and implemented.Results After implement of the non-punitive reporting system in the operating room,the adverse events reporting rate increased from 14.04% to 85.71%(P<0.01),and nurses′ cognition was significantly improved and their attitudes toward adverse nursing events reporting changed significantly(P<0.05,P<0.01).Conclusion The non-punitive,adverse nursing event reporting system in the operating room improves nurses′ cognition of and attitude towards adverse nursing events reporting,helps find out the causes of adverse nursing events,and finally eradicates similar things.