妇幼保健机构护理安全事件发生特点及影响因素分析  

Analysis on the occurrence characteristics and influencing factors of nursing safety events in maternal and child health care institutions

作　　者：马洪峰 寇文静 苏向单 郭晓丽[1] 张金燕[1] 崔慧珍 MA Hongfeng;KOU Wenjing;SU Xiangdan;GUO Xiaoli;ZHANG Jinyan;CUI Huizhen(Department of Nursing,the Third Affliated Hospital of Zhengzhou University,Zhengzhou 450052,China)

机构地区：[1]郑州大学第三附属医院护理部,河南郑州450052

出　　处：《河南预防医学杂志》2022年第10期787-790,794,共5页Henan Journal of Preventive Medicine

摘　　要：目的 回顾性分析妇幼保健机构护理安全(不良)事件,明确发生原因及临床特点,探究相关防范措施。方法 对某三级甲等妇幼保健院2020年1月至2021年12月上报的260例护理不良事件进行回顾性研究,从事件类型、发生月份、发生时间段、事件分级、事件结局、责任护士能级等方面分析临床特点。结果 妇幼保健机构260件护理安全(不良)事件中,坠床跌倒类发生率最高(21.5%),其次是操作类(15.4%)和静脉安全类(11.9%);51.5%的护理安全(不良)事件发生在白班时段;高年资护士是妇幼保健机构护理不良事件发生的高风险人群(70.0%),其主要由个人经验主义盛行、专业素养欠缺、护理信息化接受度差、临床带教不规范、规范化培训不到位导致;Ⅲ~Ⅳ级事件发生率为93.8%。结论 妇幼保健机构护理安全(不良)事件由多种因素导致,临床护理人员应动态评估跌倒/坠床风险,及时防范和干预;护理管理者合理配置白班时段人力资源;强化高年资护士风险评估和防范能力,完善风险预警评估体系。Objective To retrospectively analyze adverse nursing events from maternal and child health care institutions,to clarify the causes and clinical characteristics,so as to explore effective preventive measures.Methods A total of 260 adverse nursing events were retrospectively analyzed,which were collected from January 2020 to December in a tertiary maternal and child health care hospital.The clinical characteristics were analyzed from the aspects of event type,occurrence month,occurrence time period,event classification,event outcome,and the level of responsible nurses.Results Among the 260 adverse nursing events in maternal and child health care institutions,the incidence of falling down(21.5%) was the highest,followed by operation events(15.4%) and venous safety events(11.9%).The 51.5% of adverse nursing events occurred during dayshift;nurses with high seniority were the high-risk group of adverse nursing events in maternal and child health care institutions(70.0%);it was mainly caused by the prevalence of personal empiricism,lack of professional quality,poor acceptance of nursing informatization,non-standard clinical teaching and inadequate standardized training.The incidence of grade Ⅲ or Ⅳ events accounted for 93.8%.Conclusions Adverse nursing events in maternal and child health care institutions are caused by multiple factors.Clinical nurses should dynamically evaluate the risk of falling/falling down,and timely prevent and intervene.Nursing managers reasonably allocate human resources during dayshift;strengthen the risk assessment and prevention ability of nurses with high seniority,improve the risk early warning evaluation system.

关 键 词：妇幼保健机构 护理安全事件 不良事件 回顾性研究 

分 类 号：R197.6[医药卫生—卫生事业管理]