护理不良事件研究进展
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摘要
综述了护理不良事件的概念、重要性、发生率、原因、监测、上报、处理、管理体系等内容,为保证病人安全、进一步加强护理不良事件相关研究提供一定的理论参考。
引文
[1] 吴欣娟.医院临床护理质量安全评审指南[M].北京:中国协和医科大学出版社,2005:108.
[2] BRENNAN T A,SOX C M,BURSITN H R.Relation between negligent adverse event and the outcomes of medical mal-practice litigation[J].N Engl J Med,1996,335(26):1963-1967.
[3] 韩剑童.护理不良事件管理的研究进展[J].护理管理杂志,2014,14(5):341-343.
[4] PAPPAS H S.The cost of nurse-sensitive adverse events[J].J Nurs Adm,2008,38(5):230-236.
[5] WILSON R M,RUNCIMAN W B,GIBBERD R W,et al.The quality in Australian health care study[J].Med J Austri,1995,163(9):458-471.
[6] 李焕文.护理不良事件管理的研究进展[J].当代护士(上旬刊),2017(3):6-8.
[7] MARQUET K,CLAES N,TROY E D,et al.One fourth of unplanned transfers to a higher level of care are associated with a highly preventable adverse event:a patient record review in six belgian hospitals[J].Crit Care Med,2015(3):1.
[8] ORKAIZAGIRRE G A.The occurrence of adverse events potentially attributable to nursing care in medical units:cross sectional record review[J].Int J Nurs Stud,2014,51(6):882-891.
[9] DORAN D M,HIRDES J P,BLAIS R,et al.Adverse events among Ontario home care clients associated with emergency room visit or hospitalization:a retrospective cohort study[J].BMC Health Serv Res,2013,13:227.
[10] 丁冠云.基层医院临床护理不良事件的原因分析及防范措施[J].江苏卫生事业管理,2018,29(4):467-470.
[11] 付路易,程棣群,张翠萍.新疆某肿瘤医院89例院内上报护理不良事件原因分析及防范对策[J].中国护理管理,2015,15(7):854-856.
[12] 龚舒萍,邓传秀.某精神病专科医院60起护理不良事件原因分析及防范对策[J].全科护理,2018,16(7):835-837.
[13] 李海霞,董彩梅,吕姗.181例护理不良事件原因分析及防范对策[J].循证护理,2017,3(6):678-681.
[14] 李静.246例护理不良事件原因分析及护理对策[J].护理研究,2017,31(36):4688-4691.
[15] 童晓菲.上海市三级甲等医院护理不良事件的调查[J].解放军护理杂志,2016,33(18):22-25.
[16] NASCIMENTO C C P,MARIA C T,LEILANE A G,et al.Indicators of healthcare results:analysis of adverse events during hospital stays[J].Rev Lat Am Enfermagem,2008,16(4):746-751.
[17] 陈秀英.门诊护理不良事件原因分析与对策[J].岭南急诊医学杂志,2017,22(6):595-597.
[18] 谌娇.儿科护理不良事件原因分析与对策[J].护理实践与研究,2017,14(11):100-102.
[19] 金慧玉.SHEL模式在分析护理不良事件发生中的应用[J].转化医学杂志,2018,7(4):231-233.
[20] CAMINITI C,DIODATI F,BACCHIERI D,et al.Evaluation of a pilot surgical adverse event detection system for Italian hospitals[J].Int J Qual Health Care,2012,24(2):114-120.
[21] MARCUM Z A,ARBOGAST K L,BEHRENS M C,et al.Utility of an adverse drug event trigger tool in veterans affairs nursing facilities[J].Consult Pharm,2013,28(2):99-109.
[22] AHN H J,PARK H A.Adverse-drug-event surveillance using narrative nursing records in electronic nursing records[J].Comput Inform Nurs,2013,31(1):45-51.
[23] 董婷婷,韩斌如,杨莘.护理不良事件聚集性信号预警模型的设计与应用[J].中国数字医学,2016,11(6):70-72.
[24] Institute of Medicine.To error is human;building a safer health system[EB/OL].[2009-11-16].http://www.napedu/rata-log/9728.
[25] Department of Health.Building a safer nhs for patients:implementing an organisation with a memory[EB/OL].[2010-03-03].http://www.dh.gov.uk/en/publication.sandstatististics/publications/publications policy and guidance/dh_4065083.
[26] WOODS D,THOMAS E,HOLL J,et al.Adverse events and preventable adverse events in children[J].Pediatrics,2005,115(1):155-160.
[27] Rosenthal J B M,Flowers L.Current state programs addressing medical errors:an analysis of mandatory reporting and other initiatives [EB/OL].[2010-01-19].http://www.nashp.org/sites/default/files/medical_ errors_analysis_secsl-4.pdf.
[28] BARACH P.Reporting and preventing medical mishaps:lessons from non-medical near miss reporting systems[J].BMJ,2000,320(7237):759-763.
[29] KIM J,KIM S,JUNG Y,et al.Status and problems of adverse event reporting systems in Korean hospitals[J].Healthc Inform Res,2010,16(3):166-176.
[30] MOUMTZOGLOU A.Factors impeding nurses from reporting adverse events[J].J Nurs Manag,2010,18(5):542-547.
[31] 秦春香.不良事件上报障碍量表的修订及在护理中的应用[D].长沙:中南大学,2014.
[32] 宋朝晖.柳州市三级医院护士护理不良事件报告意向现状及影响因素与干预研究[D].南宁:广西医科大学,2014.
[33] 程红萍,刘佳.阻碍护理不良事件上报的原因分析及对策[J].护理研究,2018,32(14):2294-2296.
[34] MORRISS F H,ABRAMOWITZ P W,NELSON S P,et al.Effectiveness of a barcode medication administration system in reducing preventable adverse drug events in a neonatal intensive care unit:a prospective cohort study[J].J Pediatr,2009,154(3):363-368.
[35] 刘红玲.基于根本原因分析法的护理不良事件分析表的设计与应用[J].护理实践与研究,2015(1):92-93.
[36] 余叶嫦,李共甜,宁炳雯.根因分析法在急诊科护理不良事件管理中的应用[J].医学理论与实践,2015(4):558-559.
[37] 侯方华,孙媛媛,孙洪巧.护理安全预警交班本在心内科动态监控护理不良事件中的作用[J].黑龙江医药,2014(5):1258-1260.
[38] 彭湘群.前瞻性风险管理对降低护理不良事件发生率的影响[J].当代护士(中旬刊),2014(12):162-164.
[39] 昌子艳.品管圈活动降低急诊抢救护理不良事件的发生率[J].解放军护理杂志,2015,32(12):65-67.
[40] 蓝月,刘梦滢.品管圈在降低血透室护理不良事件中的应用[J].临床合理用药杂志,2016,9(31):148-149.
[41] 陈芝菊.非惩罚护理不良事件管理体系对于护理质量的作用[J].内蒙古中医药,2016,35(3):88-89.
[42] 胡兰苹,梁艳梅.根本原因分析法(RCA)在预防血透中心护理不良事件中的应用研究[J].实用临床医药杂志,2017,21(18):30-32.
[43] 纪冬梅.专项管理在老年住院患者护理不良事件管控中的应用[J].护士进修杂志,2018,33(3):233-236.
[44] 李琴.非惩罚性护理不良事件报告制度对急诊科护理工作质量的影响[J].中医药管理杂志,2018,26(5):196-197.
[45] 李耀丽.数据采集器对降低护理不良事件发生率的成效探析[J].青海医药杂志,2017,47(10):39-41.
[46] 骆金铠.护理不良事件上报信息的闭环管理[J].中国护理管理,2016,16(8):1029-1032.
[47] 林绍英.特性要因图质量管理工具在护理不良事件管理中的应用[J].齐鲁护理杂志,2016,22(12):103-104.
[48] 梅岚,王莉红.网络信息化直报系统在护理不良事件管理的应用效果[J].实用医技杂志,2018,25(5):562-563.
[2] BRENNAN T A,SOX C M,BURSITN H R.Relation between negligent adverse event and the outcomes of medical mal-practice litigation[J].N Engl J Med,1996,335(26):1963-1967.
[3] 韩剑童.护理不良事件管理的研究进展[J].护理管理杂志,2014,14(5):341-343.
[4] PAPPAS H S.The cost of nurse-sensitive adverse events[J].J Nurs Adm,2008,38(5):230-236.
[5] WILSON R M,RUNCIMAN W B,GIBBERD R W,et al.The quality in Australian health care study[J].Med J Austri,1995,163(9):458-471.
[6] 李焕文.护理不良事件管理的研究进展[J].当代护士(上旬刊),2017(3):6-8.
[7] MARQUET K,CLAES N,TROY E D,et al.One fourth of unplanned transfers to a higher level of care are associated with a highly preventable adverse event:a patient record review in six belgian hospitals[J].Crit Care Med,2015(3):1.
[8] ORKAIZAGIRRE G A.The occurrence of adverse events potentially attributable to nursing care in medical units:cross sectional record review[J].Int J Nurs Stud,2014,51(6):882-891.
[9] DORAN D M,HIRDES J P,BLAIS R,et al.Adverse events among Ontario home care clients associated with emergency room visit or hospitalization:a retrospective cohort study[J].BMC Health Serv Res,2013,13:227.
[10] 丁冠云.基层医院临床护理不良事件的原因分析及防范措施[J].江苏卫生事业管理,2018,29(4):467-470.
[11] 付路易,程棣群,张翠萍.新疆某肿瘤医院89例院内上报护理不良事件原因分析及防范对策[J].中国护理管理,2015,15(7):854-856.
[12] 龚舒萍,邓传秀.某精神病专科医院60起护理不良事件原因分析及防范对策[J].全科护理,2018,16(7):835-837.
[13] 李海霞,董彩梅,吕姗.181例护理不良事件原因分析及防范对策[J].循证护理,2017,3(6):678-681.
[14] 李静.246例护理不良事件原因分析及护理对策[J].护理研究,2017,31(36):4688-4691.
[15] 童晓菲.上海市三级甲等医院护理不良事件的调查[J].解放军护理杂志,2016,33(18):22-25.
[16] NASCIMENTO C C P,MARIA C T,LEILANE A G,et al.Indicators of healthcare results:analysis of adverse events during hospital stays[J].Rev Lat Am Enfermagem,2008,16(4):746-751.
[17] 陈秀英.门诊护理不良事件原因分析与对策[J].岭南急诊医学杂志,2017,22(6):595-597.
[18] 谌娇.儿科护理不良事件原因分析与对策[J].护理实践与研究,2017,14(11):100-102.
[19] 金慧玉.SHEL模式在分析护理不良事件发生中的应用[J].转化医学杂志,2018,7(4):231-233.
[20] CAMINITI C,DIODATI F,BACCHIERI D,et al.Evaluation of a pilot surgical adverse event detection system for Italian hospitals[J].Int J Qual Health Care,2012,24(2):114-120.
[21] MARCUM Z A,ARBOGAST K L,BEHRENS M C,et al.Utility of an adverse drug event trigger tool in veterans affairs nursing facilities[J].Consult Pharm,2013,28(2):99-109.
[22] AHN H J,PARK H A.Adverse-drug-event surveillance using narrative nursing records in electronic nursing records[J].Comput Inform Nurs,2013,31(1):45-51.
[23] 董婷婷,韩斌如,杨莘.护理不良事件聚集性信号预警模型的设计与应用[J].中国数字医学,2016,11(6):70-72.
[24] Institute of Medicine.To error is human;building a safer health system[EB/OL].[2009-11-16].http://www.napedu/rata-log/9728.
[25] Department of Health.Building a safer nhs for patients:implementing an organisation with a memory[EB/OL].[2010-03-03].http://www.dh.gov.uk/en/publication.sandstatististics/publications/publications policy and guidance/dh_4065083.
[26] WOODS D,THOMAS E,HOLL J,et al.Adverse events and preventable adverse events in children[J].Pediatrics,2005,115(1):155-160.
[27] Rosenthal J B M,Flowers L.Current state programs addressing medical errors:an analysis of mandatory reporting and other initiatives [EB/OL].[2010-01-19].http://www.nashp.org/sites/default/files/medical_ errors_analysis_secsl-4.pdf.
[28] BARACH P.Reporting and preventing medical mishaps:lessons from non-medical near miss reporting systems[J].BMJ,2000,320(7237):759-763.
[29] KIM J,KIM S,JUNG Y,et al.Status and problems of adverse event reporting systems in Korean hospitals[J].Healthc Inform Res,2010,16(3):166-176.
[30] MOUMTZOGLOU A.Factors impeding nurses from reporting adverse events[J].J Nurs Manag,2010,18(5):542-547.
[31] 秦春香.不良事件上报障碍量表的修订及在护理中的应用[D].长沙:中南大学,2014.
[32] 宋朝晖.柳州市三级医院护士护理不良事件报告意向现状及影响因素与干预研究[D].南宁:广西医科大学,2014.
[33] 程红萍,刘佳.阻碍护理不良事件上报的原因分析及对策[J].护理研究,2018,32(14):2294-2296.
[34] MORRISS F H,ABRAMOWITZ P W,NELSON S P,et al.Effectiveness of a barcode medication administration system in reducing preventable adverse drug events in a neonatal intensive care unit:a prospective cohort study[J].J Pediatr,2009,154(3):363-368.
[35] 刘红玲.基于根本原因分析法的护理不良事件分析表的设计与应用[J].护理实践与研究,2015(1):92-93.
[36] 余叶嫦,李共甜,宁炳雯.根因分析法在急诊科护理不良事件管理中的应用[J].医学理论与实践,2015(4):558-559.
[37] 侯方华,孙媛媛,孙洪巧.护理安全预警交班本在心内科动态监控护理不良事件中的作用[J].黑龙江医药,2014(5):1258-1260.
[38] 彭湘群.前瞻性风险管理对降低护理不良事件发生率的影响[J].当代护士(中旬刊),2014(12):162-164.
[39] 昌子艳.品管圈活动降低急诊抢救护理不良事件的发生率[J].解放军护理杂志,2015,32(12):65-67.
[40] 蓝月,刘梦滢.品管圈在降低血透室护理不良事件中的应用[J].临床合理用药杂志,2016,9(31):148-149.
[41] 陈芝菊.非惩罚护理不良事件管理体系对于护理质量的作用[J].内蒙古中医药,2016,35(3):88-89.
[42] 胡兰苹,梁艳梅.根本原因分析法(RCA)在预防血透中心护理不良事件中的应用研究[J].实用临床医药杂志,2017,21(18):30-32.
[43] 纪冬梅.专项管理在老年住院患者护理不良事件管控中的应用[J].护士进修杂志,2018,33(3):233-236.
[44] 李琴.非惩罚性护理不良事件报告制度对急诊科护理工作质量的影响[J].中医药管理杂志,2018,26(5):196-197.
[45] 李耀丽.数据采集器对降低护理不良事件发生率的成效探析[J].青海医药杂志,2017,47(10):39-41.
[46] 骆金铠.护理不良事件上报信息的闭环管理[J].中国护理管理,2016,16(8):1029-1032.
[47] 林绍英.特性要因图质量管理工具在护理不良事件管理中的应用[J].齐鲁护理杂志,2016,22(12):103-104.
[48] 梅岚,王莉红.网络信息化直报系统在护理不良事件管理的应用效果[J].实用医技杂志,2018,25(5):562-563.