282例非惩罚性网络上报护理不良事件的分析与对策  

Analysis and countermeasures of the 282 cases of nursing adverse events with non-punitive network reported

作　　者：韩美玲[1] 王芳[1] 徐淑华[1] 陈芹[1] 吴菲菲[1] 

机构地区：[1]安徽省宿州市立医院护理部,234000

出　　处：《中华现代护理杂志》2015年第27期3228-3230,共3页Chinese Journal of Modern Nursing

摘　　要：目的：通过对282例非惩罚性网络上报护理不良事件的分析,了解护理不良事件发生的特点,并制定对策,以减少护理不良事件的发生。方法回顾性分析2013年6月—2014年6月网络上报的282例非惩罚性护理不良事件,对其进行总结、分析,探讨护理不良事件的发生特点、原因、年龄段与护士层级的关系。结果282例护理不良事件中无后果事件（Ⅲ级）占67.38%,隐患事件（Ⅳ级）占26.95%。23：00—8：00发生的护理不良事件占26.60%。警告事件（Ⅰ级）中33.3%发生在15：00—23：00、66.7%发生在23：00—8：00。发生不良事件的时间段主要集中在8：00—15：00,占52.84%（149/282）。护士层级发生不良事件的比例最高,占59.93%（169/282）。发生护理不良事件的患者年龄分布中,＆gt;60岁患者占49.29%。护理不良事件发生的原因中未严格执行查对制度占30.85%,缺乏责任心占24.11%,风险意识不强占23.76%。结论实行网络上报非惩罚性护理不良事件后,各护理单元不良事件的主动上报意识明显加强,护士层级发生不良事件的比例较高,＆gt;60岁住院患者发生率较高,警告事件（Ⅰ级）多在15：00—8：00发生。应加强年轻护士培训、老年住院患者管理及15：00—8：00的护士值班管理,以减少护理不良事件的发生。Objective To understand the characteristics of the nursing adverse events through analysis the 282 cases of nursing adverse events, and make countermeasures to reduce the incidence of adverse events. Methods A total of 282 nursing adverse events of non-punitive network reported were collected from June 2013 to June 2014 with retrospective analysis, then we analyzed and summarized them, in order to find out the relationship between occurred characteristics, reasons, age group with the nurse hierarchy, etc. Results No consequence nursing adverse events （levelⅢ） accounted for 67. 38% of all events cases, while potential hazard nursing adverse events （ level Ⅳ） accounted for 26. 95%. Nursing adverse events accounted for 26. 60%happened from 23：00 to 8：00. And 33. 3% of warning events （ level Ⅰ） happened in 15：00—23：00 and 66. 7% took place in 23：00—8：00. Hence, the adverse events occurred from 8：00 to 15：00 occupying 52. 84% （149/282）. Then over 60 years old cases of nursing adverse events accounted for 49. 29%. Nursing hierarchy and its adverse events accounted for the highest rate, which was 59. 93% （169/282）. In the distribution of age group about nursing adverse events, age group of beyond 60 years old was 49. 29%. For the reasons of nursing adverse events, without strictly carrying out checking system accounted for 30. 85%, lacking responsibility occupying 24. 11%, not strong risk awareness possessing 23. 76%. Conclusions It is remarkable to improve the consciousness of reporting adverse events in each nursing unit after implementation of network reported no-punitive nursing adverse events. There is a high percentage of nursing hierarchy adverse events and over 60 years old patients occurred. Warning events （levelⅠ） frequently happen in 15：00-8：00. Therefore, we should strengthen the young nurses′training, management of senile inpatients, 15：00—8：00 period nursing duty management, in order to reduce the incidence of nursing adverse events.

关 键 词：患者安全管理 护理不良事件 非惩罚性 对策 

分 类 号：R47[医药卫生—护理学]