82例护理不良事件的根本原因分析与对策  

Root Analysis and Countermeasures of Eighty-two Nursing Adverse Events

作　　者：徐彬[1] 嵇友菊[1] 解满霞 

机构地区：[1]淮安市第四人民医院护理部,江苏淮安223002

出　　处：《解放军护理杂志》2009年第13期59-60,共2页Nursing Journal of Chinese People's Liberation Army

摘　　要：目的分析护理不良事件的最根本原因,以探讨防范对策。方法应用根本原因分析法(root cause analy-sis,RCA)对2006年1月至2007年12月的护理不良事件82例进行调查分析。结果系统原因是护理不良事件的根本原因,教育培训是系统缺陷中最多见的原因。结论为预防护理不良事件发生,应转变管理理念,强化培训教育,合理使用人力资源,实行人性化管理。Objective To investigate the preventive measures by analyzing the most fundamental reasons of nursing adverse events. Methods Eighty-two nursing adverse events from Jan. 2006 to Dec. 2007 were analyzed by root cause analysis. Results System factors were the root causes of nursing adverse events and education training was the most common system factor. Conclusion To prevent nursing errors, we should change management ideas, strengthen education training, use human resources rationally and perform human-based management.

关 键 词：护理不良事件 原因 对策 

分 类 号：R197.323[医药卫生—卫生事业管理]