脊柱外科护理不良事件根因分析  

ROOT CAUSE ANALYSIS OF NURSING ADVERSE EVENTS IN SPINAL SURGERY

作　　者：窦玲云[1] 刘伟[1] 窦秀云[2] 窦淑萍[1] 赵雅娜[1] 魏洁 张莉 

机构地区：[1]河北省唐山市第二医院,063000 [2]唐山市工人医院

出　　处：《中国煤炭工业医学杂志》2017年第11期1397-1400,共4页Chinese Journal of Coal Industry Medicine

摘　　要：目的通过根本原因分析法对骨科医院脊柱外科护理不良事件发生的原因及特点进行分析,探讨不良事件发生的原因,针对性的制定整改措施避免不良事件的发生。方法回顾该院2015年1月—2016年12月二年三个脊柱外科共发生护理不良事件68例。将根本原因分析法运用于医院脊柱外科护理不良事件管理中,对68例护理不良事件发生类别、病种、发生时段、护士层级进行回顾性分析。找出近端原因,确认根本原因,以便为针对性制定整改措施并予以实施打下基础。结果 68例护理不良事件中压疮27例、烫伤7例,好发时段为夜班;治疗错误16例,好发时段为上午班。主要原因是违规操作,制度落实不到位,风险评估及患者安全管理工作不到位,沟通不足,护士工作负荷大和临床带教工作不严谨等。另外,低年资护士是护理不良事件的高风险人群,本调查中N1护士发生护理不良事件的比例高。调查发现与其他科室比较脊柱外科2016年护理不良事件发生情况明显少于2015年护理不良事件的发生(P<0.05),说明在护理不良事件的管理中,根本原因分析法的运用可降低护理不良事件的发生。结论根本原因分析法为护理管理者提供了一种系统的减少护理不良事件发生、保证护理安全的科学方法,为规范护理行为提供了科学依据。Objective To analyze the causes and characteristics of nursing adverse events of spinal surgery in department of orthopedics, and to explore the causes of adverse events and targeted corrective actions to avoid the occurrence of adverse events. Methods Sixty- eight cases of adverse events, occurred in author＇s hospital from January 2015 to December 2016, were analyzed retrospectively. Root cause analysis was applied to the management of adverse events in hospital spine surgery, including the classification, disease types, occur- rence period and nurse level. And then we found out the cause of the end and confirmed the root causes foundation for working out the measures of corrective action and implementation. Results There were 27 cases of bedsore and 7 cases of scald in 68 cases of nursing adverse events, and good hair time was in night shift. There were 16 cases of treatment error, the morning session was excellent. The main reasons were illegal operation, not in place on rules, not in place on risk assessment and patient safety management, lack of com- munication, higher work load and not rigorous clinical teaching work. In addition, junior nurses were at high risk of adverse care events, the incidence of nursing adverse events among N1 nurses was higher in this survey. Compared with other departments, the incidence of nursing adverse events in the spine surgery department in 2016 was significantly less than that in 2015 （P〈 0.05）. This result showed that the use of root cause analysis could reduce the occurrence of nursing adverse events in the management of nursing adverse events. Conclusion Root cause analysis provides a way for nursing managers on reducing nursing adverse e- ventsand ensuring nursing safety. It provides scientific basis for standardizing nursing behaviors.

关 键 词：根本原因分析法 护理不良事件 护理安全 

分 类 号：R473.6[医药卫生—护理学]