Department of Nursing, The First People's Hospital of Xiangtan City, No. 21 Shuyuan Road, Yuetang District, Xiangtan City, 411101, Hunan, China.
Department of Nursing, Xiangtan Central Hospital, No.120 Heping Road, Yuhu District, Xiangtan City, 411100, Hunan, China.
BMC Health Serv Res. 2024 May 31;24(1):692. doi: 10.1186/s12913-024-10913-4.
To explore the application effect of the direct reporting system of adverse nursing events and special continuous nursing quality improvement measures in the management of these adverse events.
The implementation time of continuous nursing improvement based on the direct reporting system was the demarcation point. We retrospectively collected and analyzed nursing adverse event reports and hospitalization data from Xiangtan Central Hospital before implementation (2015-2018) and after implementation (2019-2022). The active reporting rate of adverse events, the composition of these events and the processing time were compared between the two groups.
The rate of active reporting of adverse events before the implementation was lower than that after the implementation (6.7% vs. 8.1%, X = 25.561, P < 0.001). After the implementation of the direct reporting system for nursing events and the continuous improvement of nursing quality, the reporting proportion of first-level and second-level events decreased significantly. Moreover, the reporting proportion of third-level events increased significantly. The proportion of falls and medication errors decreased, and the proportion of unplanned extubation, infusion xerostomia and improper operation increased. The processing time of the reported nursing adverse events was significantly reduced (31.87 ± 7.83 vs. 56.87 ± 8.21, t = 18.73, P < 0.001).
The direct reporting system of adverse nursing events and the continuous improvement measures for nursing quality can effectively improve the active reporting rate of adverse events, change their composition and reduce their processing time, as well as help create a safe psychological environment for both patients and nursing staff.
探讨不良护理事件直接报告制度与专项持续护理质量改进措施在护理不良事件管理中的应用效果。
以实施持续护理质量改进为时间节点，回顾性收集湘潭市中心医院实施不良事件直接报告制度前（2015-2018 年）和实施后（2019-2022 年）的护理不良事件报告和住院患者资料，比较两组不良事件主动报告率、构成比及处理时间。
实施不良事件直接报告制度前不良事件主动报告率低于实施后（6.7%比 8.1%，X²=25.561，P<0.001）。实施护理事件直接报告制度和持续护理质量改进后，一级、二级事件报告构成比显著降低，三级事件报告构成比显著升高，跌倒和用药错误报告构成比降低，非计划性拔管、输液口腔干燥和操作不当报告构成比升高。不良事件报告处理时间明显缩短（31.87±7.83比 56.87±8.21，t=18.73，P<0.001）。
不良护理事件直接报告制度与护理质量持续改进措施能有效提高不良事件主动报告率，改变不良事件构成，缩短处理时间，有助于营造患者和护理人员安全的心理环境。
