摘要
目的:对南京市某三级甲等医院护士上报接近失误事件及护理不良事件的发生现状进行纵向研究,为临床护理决策提供参考意见。方法:基于“拦截接近失误事件系统”及“不良事件上报系统”,收集2016年1月―2019年8月南京市某三级甲等医院护理人员主动上报接近失误事件及不良事件的数据,并分析两类事件的发展趋势及相关性。结果:研究期间接近失误事件呈先慢后快、增长趋势,护理不良事件呈先增长、后略微降低趋势。各科室护士上报接近失误事件与不良事件发生例数呈正相关(r=0.380,P<0.01),其中护理不良事件中静脉导管相关不良事件(r=0.212,P<0.05)、药物错误(r=0.305,P<0.05)、跌倒(r=0.303,P<0.01)与该科室接近失误事件呈正相关;但失禁相关性皮炎、非计划性拔管、压力性损伤、医源性皮损与该科室接近失误事件无显著相关关系(P>0.05)。结论:接近失误事件及不良事件的发展趋势具有时间差异性,呈现异相关联;同时,每个科室的两类事件发生例数也具有关联性。建议护理管理者加强对接近失误事件的监测与分析,以期降低护理不良事件发生率。
Objective:A longitudinal study was conducted on the occurrence status of near-miss events and adverse events reported by nurses in a tertiary grade A hospital in Nanjing,in order to provide reference for nursing clinical decision-making.Methods:The"intercept near-miss event system"and"adverse event reporting system"were used to collect the data of near-miss event and adverse events which were reported by nurses in a tertiary grade A hospital in Nanjing,from January 2016 to August 2019.And the occurrence trend and correlation of two kinds of events were analyzed.Results:Near-miss events showed a trend of first slow and then fast increasing,while adverse events showed a trend of first increasing and then slightly decreasing.There was a significant positive correlation between the occurrence of near-miss events and adverse events reported in every department(r=0.380,P<0.01).And venous catheter-related adverse events(r=0.212,P<0.05),drug errors(r=0.305,P<0.05),falls(r=0.303,P<0.01)were significantly positively correlated with the incidence of near-miss event.However,there were no significant correlation between incontinence-related dermatitis,unplanned extubation,stress injury,and iatrogenic skin lesions and near-miss events in these departments(P>0.05).Conclusions:The development trend of near-miss events and adverse events had time difference,showing different correlation.Besides,the correlation between cases of near-miss events and adverse events in every department was significant.It was suggested that the nursing managers should strengthen the monitoring and analysis of the near-miss events in order to reduce the incidence of nursing adverse events.
作者
徐冬梅
顾则娟
张新月
宋燕波
王荣
XU Dongmei;GU Zejuan;ZHANG Xinyue;SONG Yanbo;WANG Rong(Jiangsu Province Hospital,Jiangsu 210029 China)
出处
《护理研究》
北大核心
2021年第13期2295-2298,共4页
Chinese Nursing Research
基金
江苏省医学创新团队项目,编号:CXTDA2017019。
关键词
护理信息系统
接近失误事件
护理不良事件
护理管理
纵向研究
nursing information system
near-miss events
nursing adverse events
nursing management
longitudinal study
