主管:国家卫生健康委员会
主办:国家卫生健康委医院管理研究所
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• 护理安全 • 上一篇    下一篇

63例非计划性拔管事件分析及对策

段应龙 丁四清 张秋香 余晓 张小红   

  1. 中南大学湘雅三医院护理部
  • 出版日期:2015-10-25 发布日期:2015-10-25
  • 基金资助:
    国家临床重点专科建设项目(2013-2014)

Analysis and countermeasures of 63 unplanned extubation

  • Online:2015-10-25 Published:2015-10-25

摘要: 目的:分析非计划性拔管发生的原因,为患者导管安全和风险管理提供依据。方法:对院内不良事件上报系统收集的63 例非计划性拔管事件进行回顾性研究,对发生非计划拔管事件的患者性别及年龄,当班护士职称、工龄以及非计划性拔管的科室和发生时间进行统计学分析。结果:男性、老年和意识障碍的患者易发生非计划性拔管;ICU 及外科科室和夜间更易发生非计划性拔管;初级职称护士当班期间更易发生非计划性拔管(P <0.01);工作5 年内的护士当班期间更易发生非计划性拔管(P <0.01)。结论:对非计划性拔管事件的分析可为护理安全管理提供重要的依据,评估高危非计划性拔管患者,加强重点拔管科室的管理,注重环节质量,重点对护理人员进行相关培训,提高护士整体的风险意识和综合素质是降低非计划性拔管发生率的根本途径。

Abstract: Objective: To analyze the causes of unplanned extubation. Methods: Sixty-three unplanned extubation reported during January 2012 to December 2014 at our hospital were collected and analyzed, patients' age and gender, professional title and working years of the duty nurse involved in unplanned extubation, the occurrence time and the clinical department distribution were all analyzed. Results: Male, elder and unconsciousness were the risk factor for unplanned exbubation, the incidents happened more frequently at night than in daytime, and more frequently in ICU and surgical department than others. The duty nurses were more likely to be the junior staffs (P<0.01) and within five working years (P<0.01). Conclusion: The unplanned extubation cause analysis can provide reference to patient safety management. It is very important to assess high-risk patients, strengthen the key links management, and improve the nurses' safety knowledge to reduce the unplanned extubation.