41例院内上报护理不良事件分析  

Analysis of 41 cases of nursing adverse events reported through Intra-hospital Reporting System

作　　者：官莉[1] 李晓愚[2] 廖璞[1] 

机构地区：[1]重庆市第三人民医院,4000014 [2]重庆医科大学实验教学管理中心,400016

出　　处：《检验医学与临床》2013年第19期2518-2519,共2页Laboratory Medicine and Clinic

基　　金：重庆市卫生局科研基金资助重点项目(2010-1-50)

摘　　要：目的探讨提高患者安全管理、降低护理不良事件发生率的方法。方法回顾分析重庆市第三人民医院2012年上报的41例院内护理不良事件的原因与特点,对发生不良事件的患者性别及年龄、时间地点及不良事件的结局和分类进行统计学分析。结果 80～89岁和50～59岁患者不良事件发生率最高(53.6%);护理不良事件分类中,发生率最高的为跌倒、压疮和给药错误;不良事件上报率最高的科室为老年科、神内科、重症监护病房(ICU);院内不良事件发生的主要时间段为上午(08:00～12:00),夜间(00:00～08:00)和晚间(18:00～00:00);损伤结局中,跌倒是造成患者重度损伤的主要原因。结论医院应完善管理制度、明确岗位职责,合理排班和配置各项资源,提高护理人员的风险意识和护理水平,是减少护理不良事件的根本途径。Objective To analyze the causes and characters of adverse events reported through Intra-hospital Reporting System（IHRS）.Methods A retrospective study was conducted to analyze the adverse events collected through IHRS and statistical analysis was used to analyze items,including patients＇ age and sex,time distribution and location,classification and outcome of the adverse events.Results Incidence in old patients was the highest（55.6%）.The top three kinds of nursing adverse events were fall,pressure sores and medication errors.Department of Geriatrics,Neurology and ICU had the top three adverse event report ratio.Adverse events happened more frequently in daytime（8：00am-12：00am）,nighttime（0：00am-8：00am）and evening（6：00pm-0：00am）.Fall was the main reason causing severe injury in patients.Conclusion The fundamental way of reducing the incidence of adverse events could be the improvement of management system,the definition of responsibilities,the arrangement of resources and the nurse training to enhance risk awareness and general quality.

关 键 词：患者安全 不良事件 安全管理 

分 类 号：R542.22[医药卫生—心血管疾病]