基于非惩罚报告制度下护理不良事件报告系统的实践与改进  

The Implementation and Improvement of Nursing Incident Report System Based on Non- Punishment Arrangement

作　　者：乔建萍[1] 谭玉玲[1] 骆翠媚[1] 杜戈沙[1] 冼燕群[1] 罗朝虹[1] 刘琍容 

机构地区：[1]南方医科大学附属中山博爱医院,广东中山528400

出　　处：《深圳中西医结合杂志》2015年第22期138-140,共3页Shenzhen Journal of Integrated Traditional Chinese and Western Medicine

基　　金：广东省中山市医学科技基金项目(20102A060)

摘　　要：目的:建立非惩罚性报告制度,构建"系统管理+非惩罚性环境"积极的安全文化氛围,健全护理事件报告系统并实施,使护理管理者能掌握护理差错及事故的真实情况,并进行预警、细节完善和流程改造,达到从根源上减少护理不良事件发生,保障患者安全的目标。方法:采用比较试验,比较实施护理不良事件报告系统前、后护理不良事件上报例数及患者满意度,并进行统计学分析。结果:实施护理不良事件报告系统后,每季度护理不良事件上报例数、患者满意度较实施后均有显著升高(P<0.01)。结论:建立非惩罚性报告制度,改变传统的"责备与羞辱"文化,形成"知情文化+报告文化+公正文化+学习文化"这样一个先进安全文化氛围,是保障护理不良事件报告系统良性运作的关键因素。既能提高护士护理安全意识,也利于发现护理系统中的缺陷并进行分析,在全院预警和推广,可有效提高护理安全性,减少护理缺陷和投诉,提高患者满意度。Objective The purpose of building the none-punishment reporting system, forming healthy environment for systematic management and none-punishment system and perfecting the implementation of nursing incident report system was to help the administrators have full knowledge to the truth of nursing events. So that administrators could reduce nursing incidents from happening and guarantee the safety of the patients through detail optimizing procedure perfecting. Method To compare the numbers of reported nursing incidents and patients satisfaction before and after the implementation of nursing incidents report system. Result The reported nursing incidents and patients satisfaction had made an outstanding improvement after the implementation of nursing incidents reporting system. And the difference shown between the numbers have analytical meaning. Conclusion The key elements for smooth operation of nursing incidents report system are to change the culture of blame and humiliation, and to build a advanced safety environment. The report system can not only improve safety awareness of nurses but also helps to find out the flaws in nursing system, so it will effectively raise nursing safety, reduce mistakes and complaints and also patients satisfaction with the proper propaganda of this system.

关 键 词：非惩罚性报告制度 护理不良事件 护理安全 

分 类 号：R47[医药卫生—护理学]