139例住院痴呆患者安全事件分析  

Analysis of safety incidents of 139 cases of hospitalized patients with dementia

作　　者：邓宝凤[1] 罗昌春 马艳红[1] 高茂龙[1] 赵玉荣[1] 樊静[1] 郭建春[1] 李海芳[1] 王艳艳[1] 

机构地区：[1]北京老年医院,100095

出　　处：《中国护理管理》2015年第11期1302-1306,共5页Chinese Nursing Management

摘　　要：目的 :通过分析痴呆患者住院期间发生安全事件的原因及其特征,提出有效的防范对策,从而降低安全事件的发生率,提高护理质量。方法 :采用目的抽样法,对我院2008年1月至2015年8月发生的139例住院痴呆患者安全事件的病历和安全事件上报资料进行分析。结果 :痴呆住院患者安全事件的发生率呈逐年下降趋势。139例安全事件中,非计划性拔管54例(占38.8%),跌倒/坠床44例(占31.7%),外伤/自伤26例(占18.7%),院内发生压疮6例(占4.3%),误吸5例(占3.6%),走失2例(占1.4%),烫伤2例(占1.4%)。对139例安全事件的特点分析显示:67.6%的事件发生在夜班时段,84.2%的事件发生在病房内,88.5%的患者日常生活能力为中度及以上功能障碍,69.8%的患者跌倒风险为高风险,40.3%的患者压疮风险为非常危险,事件发生时66.2%的患者照顾者在身边,40.3%的事件发生在住院初期,58.3%的患者受到不同程度的伤害。结论:对安全事件发生的原因及其特征进行分析可为采取有效的防范措施提供依据,通过有效防范措施落实,确保患者安全,最终降低住院痴呆患者安全事件的发生率,提高满意度。Objective： The effective prevention measures are put forward, which can reduce the occurrence of security incidents and improve the quality of nursing, by analyzing the causes and characteristics of the safety incident of hospitalized patients with dementia. Method： The occurrence of security incidents which happened in 139 cases of hospitalized patients with dementia from January 2008 to August 2015 were analyzed through the method of the purpose of sampling. Result： The incidence of dementia inpatients security incident showed a trend of decline year by year.139 cases of security incidents had 54 cases of unplanned extubation （38.8%）, 44 cases fall/drop of bed （31.7%）, 26 eases of trauma/injury in （18.7%）, 6 cases of pressure ulcer （4.3%）, 5 cases of aspiration （3.6%）, 2 cases of lost （1.4%）, 2 cases of scald injury （1.4%）. By analyzing to characteristics of 139 cases of the security event analysis, 67.6% of the events occurred in the night time, 84.2% of the events occurred in the ward, 88.5% of the patients activities of daily living （ADL） was moderate and above dysfunction, 69.8% of patients had high fall risk, 40.3% of patients with pressure ulcer risk is very dangerous, the 66.2% incident occurred when the caregivers accompanied the patients around, 40.3% of the incident occurred in the initial stage of hospitalization, 58.3% of patients were subject to different degrees of damage. Conclusion： It can provide the basis for taking effective preventive measures by analyzing the causes and characteristics of the security incidents. It can ensure the safety of patients, ultimately reduce the occurrence of security incidents in hospitalized patients with dementia, and improve the patients satisfaction through effective preventive measures to implement.

关 键 词：住院 痴呆患者 安全事件 护理对策 

分 类 号：R47[医药卫生—护理学]