关键词: 二级医院, 护理不良事件, 根本原因分析法

Abstract: Objective To analyze the root cause of nursing adverse events and formulate the corresponding measures. Methods The status of 49 nursing adverse events were analyzed retrospectively, the primary causes were traced to enable control measures to be devised. Results Accidents which including bed fall, tumble and empyrosis, unplanned extubation, infusion reaction, extravasation of drugs were the top four rankings of nursing adverse events. In the departments including general surgery, Neonatology, ICU, Obstetric, the incidence of adverse events was higer than that of other departments. The nurses with less than 5 years of service were predominant in the nurse responsible for the adverse events, accounting for 66.4%. Conclusion It shoud be strengthened to train the junior nurse and to manage variety catheters, the risk assessment of a high-risk group should be carried out to reduce the occurrence of accidents and to ensure the patients safety.

Key words: grade-two hospital, nursing adverse events, root cause analysis methods