基于清单管理的护理风险管理信息化平台的构建及应用  

Construction and application of the information platform for nursing risk management based on checklist management

作　　者：席祖洋[1] 李茶香[1] 刘静兰[1] 郭蓉[2] 田飞 魏永婷 XI Zuyang;LI Chaxiang;LIU Jinglan;GUO Rong;TIAN Fei;WEI Yongting(Nursing Department,The First College of Clinical Medical Science,Three Gorges University,Yichang,Hubei province,443003,China)

机构地区：[1]三峡大学第一临床医学院/宜昌市中心人民医院护理部,湖北省宜昌市443003 [2]三峡大学第一临床医学院/宜昌市中心人民医院肿瘤科,湖北省宜昌市443003 [3]三峡大学第一临床医学院/宜昌市中心人民医院重症医学科,湖北省宜昌市443003

出　　处：《中国护理管理》2025年第1期101-106,共6页Chinese Nursing Management

基　　金：湖北省卫生健康领域省级标准化试点项目(2024-12);湖北省地方标准制修订项目(T-Z-05-2024207);宜昌市医疗卫生研究项目(A24-2-020)。

摘　　要：目的:构建基于清单管理的护理风险管理信息化平台,并探讨其应用效果,以期为护理风险防范及控制提供参考借鉴。方法:以4R危机管理理论为指导查找临床护理中的风险点,系统检索、整合证据并引入临床情境,形成风险管理操作清单并构建信息化管理平台,设置风险预警机制。于2021年1月起开始临床应用,比较应用前后护理不良事件发生例数、服务效率指标、护士满意度等指标的差异。结果:在高风险药品、仪器设备、高风险护理操作、疾病并发症、宣教与护患沟通、专科病区风险、护理敏感指标等8个方面建立342个风险管理清单并植入信息化平台,应用后我院护理不良事件发生率由246.74/10万下降至42.48/10万,年度变化百分比(APC)为-61.50%(P<0.001);服务效率和护士满意度稳步提升,效果显著。结论:基于清单管理的护理风险管理信息化平台能够有效减少护理不良事件的发生率并提高服务效率,具有一定的借鉴价值。Objective:To construct,analyze and assess the information platform for nursing risk management based on checklist management,in order to provide reference for nursing risk prevention and control.Methods:Clinical nursing risk points were found under the guidance of 4R crisis management theory.Then evidence was systematically retrieved and integrated combining with clinical situations to form a risk management checklist to finally build the information management platform,which was applied to practice from January 2021.The differences between the number of adverse nursing events,service efficiency,nurse satisfaction were compared before and after the application of the platform.Results:A total of 342 checklists were established and implanted into the information platform referring to 8 aspects,including high-risk drugs,instruments and equipment,high-risk nursing practices,disease complications,education and nurse-patient communication,risks of specialized wards,nursing-sensitive indicators,etc.After the application,the incidence of nursing adverse events decreased from 246.74/100,000 to 42.48/100,000,and the annual percentage change was-61.50%(P<0.001);the service efficiency and nurse satisfaction increased steadily with remarkable effects.Conclusion:The information platform for nursing risk management based on checklist can effectively reduce the occurrence of nursing adverse events and improve their service efficiency to provide certain reference for clinical practice.

关 键 词：清单 风险管理 护理管理 循证护理 护理信息化 

分 类 号：R47[医药卫生—护理学] R197[医药卫生—临床医学]