Cause analysis and improvement measures of nursing adverse events

1, the inspection system is not in place.

In practical nursing work, adverse events caused by not seriously implementing various inspection systems still account for a high proportion. The specific manifestations are that the medication examination is not strict, and sometimes it depends on subjective impression, such as calling the bed number instead of the name when treating patients, and not comparing the name, drug name and infusion card when changing fluids, which leads to infusion errors or oral medication errors.

2. Incorrect execution of doctor's advice

It is manifested in blindly executing the wrong doctor's advice, violating the oral doctor's advice, misreading the doctor's advice, and sometimes relying on subjective impressions, failing to find out the changes in patients' dosage in time and affecting patients.

The execution time of the doctor's advice is not strict, including not delivering the medicine to the mouth or delaying or taking the medicine 2 hours in advance, taking it by mistake, missing it, taking it too much or even taking it without authorization. Some missed the drug allergy test or redone it without observing the results in time after the allergy test, and failed to carry out the doctor's advice in time during the rescue.

3. The nursing rules and regulations are not strictly implemented, which violates the operating rules of nursing technology. Because there are more junior nurses and lack of work experience, they are not familiar with some specialized knowledge, basic common sense and operating procedures, and are not familiar with the workflow.

The patient's condition was not carefully observed, and the nursing measures were not in place: the bedridden patient did not turn over in time, resulting in pressure sores, violating the surgical safety inspection system, causing instruments and gauze to be forgotten in the surgical incision, violating the nursing operation rules, and causing the patient to suffocate due to nasal feeding by family members.

The extravasation of intravenous drug solution causes local tissue necrosis, and various examinations and operations are affected by omission of skin preparation or multiple scratches on skin preparation: improper gastric lavage operation causes gastric perforation; Hot compress burn patients or cold compress frostbite patients.

4. The nursing grading system was not strictly implemented.

Patients were not observed and patrolled in strict accordance with the grading nursing system, and the patient handover system was not seriously implemented. Health education and education are not in place, and there is no foresight for possible adverse consequences, such as not repeatedly emphasizing potential safety hazards (falling and falling from bed) to patients.

5. Nurses' ability to evaluate patients is insufficient.

The patients with high risk factors of pressure ulcer were not evaluated, which caused the patients with pressure ulcer. Patients with high risk factors of falling were not evaluated and preventive measures were taken, which led to patients falling and falling out of bed.

6. Nurses' negative burnout can easily lead to nursing adverse events. Because of trivial nursing work, high technical and service requirements, high mental tension and great ideological pressure, it is easy to cause nurses' negative burnout, which is manifested in lack of concentration, lack of enthusiasm in work and indifference to patients (patient complaints).

7, drug management confusion

It is manifested in: drugs are mixed, toxic drugs are mixed with generic drugs, injections are mixed with oral drugs, drugs for internal use are mixed with drugs for external use, the labels of medicine bottles are inconsistent with the drugs contained, drugs are out of date, drugs that need to be refrigerated are not stored in the refrigerator, especially high-concentration drugs are placed separately without labels, which leads to nursing adverse events.

8. Nurses have poor safety awareness.

Lack of nursing safety knowledge, lack of training for new employees and routine nursing training for diseases in this specialty, nurses' inexperience, ignorance of the therapeutic purposes and effects of certain drugs in different ways, inability to judge and respond to changes in illness in time, poor emergency response ability, and some mistakes that should not occur.

9. The logistics system is not perfect.

Hospital logistics is the foundation of the whole hospital management and an important support and guarantee system for the normal operation of the hospital. With the continuous development of hospital discipline construction, the progress of modern technology and the expansion of equipment scale, the scope and knowledge of logistics work are getting wider and wider, the difficulty of logistics management is getting bigger and bigger, and the degree of logistics management specialization is getting higher and higher.

Drugs can't be delivered to the ward in time. Can't provide one-stop service. Submit an article for repair.

Extended data:

Measures to prevent nursing errors and accidents;

1, strictly implement the system of three checks and ten pairs of nursing.

2. Strictly implement the nursing grading system, closely observe the changes of illness, add protective fences to the old and young, coma patients as needed, apply safety restraint belts to the restless patients to prevent them from falling off the bed, and patients with mental disorders and suicidal tendencies should closely observe the dynamics to prevent accidents due to negligence of nursing staff.

3, strengthen the management of all kinds of drugs, injection drugs and oral drugs, oral drugs and external drugs are placed separately, drug bottles are consistent with the drugs contained, drugs are checked regularly, marked when using, used first in the near future, adjusted in time to ensure that there is no expiration, the drug counter is locked, managed by special personnel, and strictly handed over.

4, regularly check all kinds of first-aid drugs, articles, first-aid equipment, strict handover, ensure good function is complete, make the rescue smoothly.

5. All the nursing measures were put in place, and the health education achieved the expected effect, which prevented the occurrence of burns, frostbite and bedsore and reduced the nursing risk.

6. Strictly implement disinfection and isolation system to prevent iatrogenic infection caused by nursing operation.

7. Regularly check the electricity consumption of departments, publicize the use of oxygen for fire prevention and theft prevention, and use the words "away from fireworks" for oxygen to ensure the safety of patients.

8, strictly implement the nursing adverse event reporting system, nurses in the work of adverse events, should immediately notify the doctor and the head nurse, and report step by step, after discussion, formulate corrective measures to prevent such incidents from happening again.

9, improve the comprehensive quality of nurses, including medical ethics, professional, technical, physical and psychological quality, is the guarantee to do a good job in nursing.

10, learn relevant nursing laws and regulations, and understand the potential legal problems in nursing work and the nursing documents of mistakes, negligence, infringement and dereliction of duty in self-care guidance.

1 1. Nurses actively adjust their mentality, reasonably arrange their work and rest time to reduce their nervousness and anxiety, improve their ability to withstand various pressures, and do a good job in nursing with a positive and optimistic attitude.