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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住院患者输液身份确认近似差错事件的调查分析

章雅杰 钟初雷   

  1. 绍兴市人民医院护理部
  • 出版日期:2015-04-25 发布日期:2015-04-25

The investigation of occurrence of the near miss for the identification of hospitalized patients with venous transfusion

  • Online:2015-04-25 Published:2015-04-25

摘要: 目的:了解住院患者输液身份确认近似差错事件发生概率及特点。方法:从本院信息系统获取2013 年住院患者输液身份确认近似差错相关数据并统计不同年龄、不同学历、不同职称的操作护士以及不同科室、不同班次近似差错事件发生概率。结果:住院患者输液身份确认近似差错发生概率约为0.320‰;不同科室、不同班次近似差错发生概率差异有统计学意义。结论:应加强近似差错高概率发生科室核对流程的管理,强化夜班身份确认管理,推广应用手持终端床边核对系统。

Abstract: Objective: To analyze the probability and characteristics of occurrence of the near miss for the identification of hospitalized patients with venous transfusion. Methods: We collected the data from the information system about the the probability of occurrence of the near miss for the identification of hospitalized patients with venous transfusion in 2013 and calculated the difference among the operating nurses of different ages, educational backgrounds, job titles, departments and shifts. Results: The probability of occurrence of the near miss for the identification of hospitalized patients with venous transfusion was 0.320‰. The probability of occurrence of the near miss among nurses of different ages, educational backgrounds and job titles had no significant difference, however, the probalility among nurses of different departments and shifts had significant statistical difference. Conclusion: Double-check process management, the identity confirmation management in night shift, and popularization of a hand-held terminal bed check system should be strengthened in the departments of high probability of occurrence of near miss.