摘要
目的通过全面分析，寻找防范护理差错重复发生的对策与启示。方法回顾2003～2006年间三家二甲医院的60例护理差错，分析差错的内容、环节，并在SHEL分析法基础上建立要素分解表，分析差错的成因。结果在差错内容构成中，注射类差错占53．3％，医嘱处理表占21．7％，病情观察类占11．7％，皮肤护理类及其他类各占6．7％，其中单人查对的接（挂）瓶环节占频次最高的注射类差错的71．9％。在差错成因中，与人员素质和能力有关（s）占68．3％，与硬件有关（H）占26．7％，与临床环境有关（E）占25．0％，与当事人及他人有关（L）占76．7％。结论护理管理者应注重对护理差错的全面系统分析，科学归因，避免单纯归咎于当事人，从而能够针对性地改进环节，调控护士的负面情绪，营造安全的文化氛围。
Objective To study countermeasures of preventing and controlling nursing error by multi - analyze. Methods Reviewing 60 nursing errors happening in 3 second level hospitals from 2003 to 2006, analyzing the content, link, analyzing the causes with the element - table based on SHEL analysis. Results In content aspect, injection errors account for 53.3 percent, doctor＇s orders performing errors account for 21.7 percent, patient＇s condition observing errors account for 11.7 per cent, skin nursing errors and the others each account for 6. 7 percent. In course aspect, relation to soft accounts for 68. 3 percent, relation to hardware accounts for 26.7 percent, relation to environment accounts for 25.0 percent, relation to litigant and the others accounts for 76. 7 percent. Conclusion Nursing managers should pay more attention to multi - analyze errors in a scientific way, avoiding to put all the blame on litigant alone, so as to improve link effectively, regulate and control moodiness, build safety culture atmosphere.
出处
《国际护理学杂志》
2007年第5期497-499,共3页
international journal of nursing
关键词
护士
护理差错
护理管理
全面分析
Nurse
Nursing error
Nursing management
Multi -analyze
