日安全分享在护理不良事件管理中的实施
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女,本科,副主任护师,护士长

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广东省护理学会科研课题资助项目([2019]002号gdhlxueh2019zx 149)


Implementation of daily safety sharing in management of adverse nursing events
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    目的 探讨基于信息系统的日安全分享在护理不良事件中的管理成效。 方法 采取历史对照法,将2018年10月至2019年9月22个护理单元设为实施前组(收治病例11 992例),全院不良事件在护理部每季度发放的护理质量报表中分享,护士长仅有本科室护理不良事件查询权限;将2019年10月至2020年9月22个护理单元设为实施后组(收治病例13 527例),护士长固定于晨8:00前进入不良事件分享平台,对全院前24 h发布的不良事件信息进行阅读,并于晨间交接班后,分享与本科室高度相关或有潜在相关性的不良事件,与护士讨论相关流程及处理措施。 结果 两组不良事件发生相对危险度(RR)为0.629,95%CI为0.492~0.804。实施后组不良事件严重程度显著低于实施前组(P<0.01)。实施后临床护士不良事件重视程度、不良事件分享态度、科学处理不良事件能力、自我学习及成长得分显著高于实施前(均P<0.01)。 结论 基于信息系统的日安全分享为不良事件沟通提供平台,可降低不良事件发生及严重程度,提升护士安全意识及不良事件控制能力。

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    Objective To explore the effect of applying daily safety sharing based on information system in management of adverse nursing events. Methods With comparative-historical design, 22 nursing units, which had a hospitalization of 11 992 patients spanning from October 2018 to September 2019, were seen as the pre-sharing group.During the period, the adverse nursing events were compiled by the department of nursing, and shared quarterly in quality reports.The head nurses of the units had limited access to check on the adverse nursing events occurring only in their units. The same 22 nursing units, which had a hospitalization of 13 527 patients spanning from October 2019 to September 2020, were seen as the post-sharing group.During the period, the head nurses of the units logged in the adverse events sharing platform before 8:00 am, and had full access to check on all the adverse nursing events occurring within the last 24 h.Then after morning handovers, the head nurses shared the adverse nursing events that were highly or potentially related with their own units, with their nurses, and discussed the process and management mea-sures of such kind of adverse nursing events. Results The relative risk ratio (RR) for adverse nursing events in the 2 groups stood at 0.629, 95%CI (RR):0.492-0.804. The severity of adverse nursing events in the post-sharing group was significantly milder (P<0.01) than in the pre-sharing group.After daily safety sharing practice, the nurses working in the units saw significant improvement in the scores of attention to adverse nursing events, attitude towards solving adverse events, ability to handle adverse events, and personal growth (P<0.01 for all). Conclusion Daily safety sharing based on information system provides a platform for adverse event communication, significantly reduces the incidence rate and severity of adverse events, and improve nurses′ safety awareness and ability to handle adverse events.

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向清华,黄志华,欧阳慕容,李秋明.日安全分享在护理不良事件管理中的实施[J].护理学杂志,2021,36(19):58-61

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  • 收稿日期:2021-05-15
  • 最后修改日期:2021-07-16
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  • 在线发布日期: 2022-12-12