根本原因分析法在某二级综合医院护理不良事件中的应用实践  

Applications of root cause analysis on nursing adverse events in one local general hospital

作　　者：张瑞红[1] 马亚洁[1] 王叶[1] 

机构地区：[1]河北省唐县人民医院,河北唐县072350

出　　处：《医学研究与教育》2014年第3期54-57,共4页Medical Research and Education

摘　　要：目的通过根本原因分析法(RCA)分析某二级综合医院的护理不良事件,进行原因分析并制定相应对策。方法对2013年某二级综合医院上报医院的49例护理不良事件汇总行RCA分析。结果护理不良事件前四位分别是坠床、跌倒、烫伤等意外事件,非计划性拔管,输液不良反应,药物外渗;发生不良事件相对较多的科室为普外科、新生儿科、重症监护室、产科;5年以下低年资护士发生不良事件占66.4%。结论应加强年轻护士的培训,做好高危病人的评估,加强管路管理,减少意外事件的发生,以提升护理安全。Objective To analyze the root cause of nursing adverse events and formulate the corresponding measures. Methods The status of 49 nursing adverse events were analyzed retrospectively, the primary causes were traced to enable control measures to be devised. Results Accidents which including bed fall, tumble and empyrosis, unplanned extubation, infusion reaction, extravasation of drugs were the top four rankings of nursing adverse events. In the departments including general surgery, Neonatology, ICU, Obstetric, the incidence of adverse events was higer than that of other departments. The nurses with less than 5 years of service were predominant in the nurse responsible for the adverse events, accounting for 66.4%. Conclusion It shoud be strengthened to train the junior nurse and to manage variety catheters, the risk assessment of a high-risk group should be carried out to reduce the occurrence of accidents and to ensure the patients safety.

关 键 词：二级医院 护理不良事件 根本原因分析法 

分 类 号：R47[医药卫生—护理学]