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作 者:姚媛媛[1] 赵振华 邢星敏 许艳[1] 柏如静 冯波[1] YAO Yuanyuan;ZHAO Zhenhua;XING Xingmin;XU Yan;BAI Rujing;FENG Bo(Department of Critical Care Medicine,Gulou Hospital affiliated to Medical College of Nanjing University,Nanjing,210008,China)
机构地区:[1]南京大学医学院附属鼓楼医院重症医学科,南京市210008
出 处:《中国护理管理》2021年第10期1518-1522,共5页Chinese Nursing Management
基 金:十三五南京市卫生青年人才培养工程(QRX17058)。
摘 要:目的:构建危重患者护理交班清单,以提高护理交班质量,保证患者安全。方法:采用实地观察、文献查询、专家会议等方法对危重患者护理交班清单进行信息项确认,并将清单以表单形式嵌入医院重症监护系统,共包括6大类41项,即患者资料16项、治疗干预8项、护理评估8项、专科护理1项、护理安全事件3项和备注信息5项,由研究者收集清单应用前后护士交接班错漏次数、床边交班时间、因交接班信息缺陷导致患者出现治疗中断等事件的次数、书写交班报告时间,同时通过访谈护士对清单的使用感受,评价清单应用效果。结果:危重患者护理交班清单的应用,显著降低了护士的交接班错漏次数、因交接班信息缺陷而导致患者出现治疗中断等事件的次数,缩短了护士书写交班报告时间(P<0.05),同时给护理人员带来正性使用感受。结论:危重患者护理交班清单借助信息系统实现了数据共享,改变了固有的临床护理工作模式,提高了临床护理质量。Objective:To construct a nursing handover checklist for critically ill patients,so as to improve the quality of nursing handover process and ensure the safety of patients.Methods:The methods of field observation,literature review and expert panels were used to confirm the information items of the nursing handover checklist.The checklist was embedded into the intensive care system as a form,included 6 categories and 41 items,which were 16 items regarding patient information,8 items regarding treatment interventions,8 items regarding nursing assessment,1 item regarding specialized nursing,3 items regarding nursing safety events,and 5 items regarding notes.The number of errors or omissions during nursing handover,the bedside handover time,the number of adverse events caused by the defect of handover information,the time of writing nursing handover checklist were collected before and after the application of the checklist.Nurses were interviewed at the same time to evaluate the application effects of the checklist.Results:After the application of the nursing handover checklist for critically ill patients,the numbers of mistakes and omissions of nurses,numbers of adverse events caused by the defect of handover information were significantly reduced,the time for nurses to write handover reports was significantly shortened(P<0.05).At the same time,nurses expressed positive experience using the checklist in the interview.Conclusion:The nursing handover checklist for critically ill patients can achieve information sharing with the help of information system.It can change the inherent mode of clinical nursing work,and improve the quality of nursing care.
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