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目的通过分析护理不良事件发生的原因和特点,探讨减少不良事件发生的措施。方法回顾性分析2012年1月-2013年6月间127起护理不良事件。结果排在前三位的不良事件依次是给药错误、遗忘治疗、沟通不良;发生的主要原因是未严格执行护理核心制度,知识经验缺乏,沟通表达能力欠缺;不良事件中,护士发现79起,医生发现28起,患者或家属发现20起。结论制定预防措施,提倡人人参与安全管理,营造安全氛围。
Objective To analyze the causes and characteristics of adverse events in nursing care and discuss the measures to reduce the incidence of adverse events. Methods Retrospective analysis of 127 cases of adverse events of nursing between January 2012 and June 2013 were retrospectively analyzed. Results The top three adverse events were misdosing, forgetful treatment and poor communication. The main reasons for this were the failure to strictly enforce the nursing care system, the lack of knowledge and experience and lack of communication skills. Among the adverse events, 79 , 28 cases were found by doctors and 20 cases were found by patients or their families. Conclusion Formulate preventive measures to promote everyone’s participation in safety management and create a safe atmosphere.