Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden.
Faculty of Health and Society, Malmö University, Malmö, Sweden.
J Clin Nurs. 2018 Jan;27(1-2):e354-e362. doi: 10.1111/jocn.13914. Epub 2017 Dec 4.
To identify the most common serious adverse events that occurred in nursing homes and their most frequent contributing factors to the improvement of safe nursing care.
There is a need to improve safe nursing care in nursing homes. Residents are often frail and vulnerable with extensive needs for nursing care. A relatively minor adverse event in nursing care can cause serious injury that could have been preventable.
This was a retrospective study, with a total sample of data regarding adverse events (n = 173) in nursing homes, concerning nursing care reported by healthcare providers in Sweden to the Health and Social Care Inspectorate. The reports were analysed with content analysis, and the frequencies of the adverse events, and their contributing factors, were described with descriptive statistics.
Medication errors, falls, delayed or inappropriate intervention and missed nursing care contributed to the vast majority (89%) of the serious adverse events. A total of 693 possible contributing factors were identified. The most common contributing factors were (i) lack of competence, (ii) incomplete or lack of documentation, (iii) teamwork failure and (iv) inadequate communication.
The contributing factors frequently interacted yet they varied between different groups of serious adverse events. The resident's safety depends on the availability of staff's competence as well as adequate documentation about the resident's condition. Lack of competence was underestimated by healthcare providers.
Registered nurses and assistant nurses need to have awareness of contributing factors to adverse events in nursing care. A holistic approach to improve patient safety in nursing homes requires competence of the staff, safe environments as well as resident's and relative's participation.
确定在养老院发生的最常见的严重不良事件及其对改善安全护理的最常见促成因素。
需要提高养老院的安全护理水平。居民通常身体虚弱，易受伤害，需要广泛的护理。护理中的相对较小的不良事件可能会造成严重伤害，而这些伤害本来是可以预防的。
这是一项回顾性研究，对瑞典医疗保健提供者向卫生和社会保健监察局报告的有关养老院护理的不良事件（n=173）的数据进行了总体样本分析。对报告进行了内容分析，并使用描述性统计方法描述了不良事件及其促成因素的频率。
用药错误、跌倒、干预延迟或不适当以及护理缺失是导致绝大多数（89%）严重不良事件的原因。确定了 693 个可能的促成因素。最常见的促成因素是（i）缺乏能力，（ii）不完整或缺乏文件记录，（iii）团队合作失败，以及（iv）沟通不足。
促成因素经常相互作用，但在不同的严重不良事件组之间存在差异。居民的安全取决于工作人员能力的可用性以及有关居民病情的充分文件记录。医疗保健提供者低估了能力不足的问题。
注册护士和助理护士需要了解护理不良事件的促成因素。从整体上提高养老院患者安全水平需要员工的能力、安全的环境以及居民及其家属的参与。
