病人护理安全事件自愿报告探索与事件分析  

Exploring voluntary report of nursing related patient safety events and analysis of the events

作　　者：刘义兰[1] 李芬[1] 黄行芝[2] 赵光红[1] 许娟[1] 胡德英[1] 王桂兰[1] 张亮[3] 

机构地区：[1]华中科技大学同济医学院附属协和医院,武汉市430022 [2]荆门市第一人民医院护理部 [3]华中科技大学同济医学院医药卫生管理学院

出　　处：《中国护理管理》2009年第3期42-44,共3页Chinese Nursing Management

基　　金：湖北省科技攻关项目基金(2007AA301B27-7)

摘　　要：目的:探讨护理相关病人安全事件获取的方法;分析护理相关病人安全事件的现状与相关因素。方法:采用护理人员自愿报告法和对病人访谈法,对2935例病人发生的护理相关安全事件的资料进行收集,并分析事件的类型、后果、原因、可预防性等。结果:护理人员自愿报告了141起与护理相关的安全事件,分为14类。结论:在一种非惩罚的环境中,护理人员能积极报告差错及非差错性等事件;威胁病人安全事件的发生往往是系统中多个环节存在问题所致;建立一个非惩罚自由报告差错等事件的系统以及以此为基础的护理安全管理模式是非常必要的。Objective：To explore the method to find nursing related patient safety events and analyze the status and influence factors of nursing related events. Methods： All data about nursing related patient safety events of 2935 patients were collected by nurses＇ self report and patients＇ interview. The types, causes, outcomes and prevention of these events were analyzed. Results： Among 2935 inpatients observed, 141 nursing-related safety events which could be divided into 14 types were reported by nurses. Conclusion： Under the non-punitive environment, nurses can report the events related to nursing, both accidents and others. The occurrences which threatened patients＇ safety often were caused by a lot of problems existing in different parts of one system. The establishment of non-punitive incident reporting system and nursing safety management model based on this system were necessary.

关 键 词：病人安全 护理差错 安全事件 自愿报告 

分 类 号：R47[医药卫生—护理学] R155.3[医药卫生—临床医学]