基于瑞士奶酪模型的患者安全链式管理体系研究  

Research on Patient Safety Chain Management System Based on Swiss Cheese Model

作　　者：关汭昕 赵晓霜[1] 李虹彦[1] 赵晓甦[1] 丛悦[1] 殷欣[1] GUAN Ruixin;ZHAO Xiaoshuang;LI Hongyan(The First Hospital of Jilin University,Changchun,Jilin,130021,China;不详)

机构地区：[1]吉林大学第一医院,吉林长春130021

出　　处：《中国卫生质量管理》2025年第1期47-52,共6页Chinese Health Quality Management

基　　金：吉林省医疗卫生人才专项(编号:JLSWSRCZX2023-61)。

摘　　要：目的探讨基于瑞士奶酪模型的患者安全链式管理体系及其应用效果。方法成立以护理部、护理质量安全管理委员会为主导的管理团队,构建基于瑞士奶酪模型的患者安全链式管理体系,包括安全文化培植链、“委员会-护士-患者”三方人员协作链、环境-个体交互链及系统闭环监管链,并将该体系应用于患者安全管理。结果体系应用后,护理人员的患者安全文化得分、患者安全文化积极反应率、患者安全文化评价构成均有所提升。每百出院人次Ⅳ级不良事件、Ⅰ~Ⅲ级不良事件上报例数均呈先快速增长、后略微下降趋势。结论基于瑞士奶酪模型的患者安全链式管理体系能够有效提升患者安全文化水平及不良事件上报率,提高医院患者安全管理水平。Objective To explore the patient safety chain management system based on Swiss cheese model and its application effect.Methods A management team led by the nursing department and the nursing quality and safety management committee was established to construct a patient safety chain management system based on the Swiss cheese model,including patient safety culture cultivation chain,tripartite personnel cooperation chain of"committee-nurse-patient",environment-individual interaction chain and system closed-loop supervision chain.The system was applied to patient safety management.Results After the application of the system,the scores of patient safety culture,the positive response rate of patient safety culture and the composition of patient safety culture evaluation of nursing staff were improved.The number of reported grade IV adverse events and grade I-III adverse events per 100 discharges increased rapidly and then decreased slightly.Conclusion The patient safety chain management system based on Swiss cheese model can effectively improve the level of patient safety culture and the reporting rate of adverse events,and improve the level of hospital patient safety management.

关 键 词：瑞士奶酪模型 链式管理 安全文化 患者安全 

分 类 号：R197.323[医药卫生—卫生事业管理]