摘要
目的研究不良事件发生的原因,为改进不良事件管理模式提供依据。方法某三甲医院2015-2017年1-12月各科室主动上报的不良事件2 849例。其中,2015年813例,2016年924例,2017年1 112例。采用回顾性分析的方法,对不良事件发生的原因、分类、等级等因素进行综合分析。结果不良事件分类中排在前5位的分别是输液输血事件、坠床跌倒、院内压疮、标本事件和药物事件,该五类不良事件占所有不良事件的53.6%。因个人因素引起的不良事件占29.63%,其中责任心不够占13.06%,护理操作不当占4.53%。不良事件上报数量居前5位的科室分别是呼吸科、急诊科、肾病科、消化内科和心血管科。非手术科室上报的不良事件多于手术科室,医源性不良事件当中,Ⅱ级事件和Ⅲ级事件较多。结论有效利用不良事件报告体系,加强事前,事中和事后的精细化管理,可以降低医疗风险,提高医疗质量和患者满意度。
Objective To study the causes of adverse events and provide basis for improving the management model of adverse events.Methods From January to December,2015to2017,2849cases of adverse events were reported voluntarily by departments of tertiary hospital.Among them,813cases were in2015,924cases in2016and1121cases in2017.By means of retrospective analysis,the causes,classifications and grades of adverse events were comprehensively analyzed.Results The top five types of adverse events were transfusion events,falling in bed,pressure sores in hospital,sample events and drug events,which accounted for53.6%of all adverse events.Adverse events caused by personal factors accounted for29.63%,of which the lack of responsibility accounted for13.06%,and improper nursing operation accounted for4.53%.The top five departments reporting adverse events were respiratory department,emergency department,nephrology department,digestive medicine department and cardiovascular department.Nonsurgical departments reported more adverse events than surgical departments.Among iatrogenic adverse events,there were more classⅡevents and classⅢevents.Conclusion By effective use of adverse event Reporting system,refinement management of the pre-and post-incident was strengthened,medical risk were reduced,and the quality of medical care and patient satisfaction were improved.
作者
祖木热提.吐尔洪
张晨
杨莹
Zumrat Turhun;ZHANG Chen;YANG Ying(Xinjiang Medical University,Urumqi 830011,China;The Fifth Affiliated Hospital,Xinjiang Medical University,Urumqi 830054,China)
出处
《新疆医科大学学报》
CAS
2018年第12期1563-1565,1570,共4页
Journal of Xinjiang Medical University
基金
新疆医科大学人文社会科学基金-改革与发展专项(2017XYFG116)
关键词
医疗安全(不良)事件
管理模式
上报制度
medical safety(adverse)incident
management mode
escalation system
