Retrospective study of nursing care adverse events at high altitude area of Lhasa city / 中国实用护理杂志

ABSTRACT

Objective To understand the status and features of nursing care adverse events and to offer scientific basis for improving patient safety management of nursing at high altitude area. Methods Data such as categories, causes, time distribution and other factors of nursing care adverse events were collected from January 2013 to August 2014 in the People′s Hospital of Tibet Autonomous Region were analyzed. Results Over the study period, 50 adverse events were recorded and the most common types were tube emersion(26%,13/50), pressure sores(14%,7/50) and scald(12%,6/50) respectively. The proportions of different severity of adverse events were hidden events (48%,24/50), events without bad consequence(36%,18/50), adverse events(14%,7/50) and warning events(2%,1/50) respectively. The ineffective communication, inadequate assessment, and not abiding by the rules accounted for 70%(35/50) of the causes of adverse events. 7:00-10:59 and 19:00-22:59 period was the high incidence of adverse events, respectively accounted for 32%(16/50) and 26%(13/50). Conclusions The management of nursing adverse events at high altitude area need to consider the geographical characteristics,besides, to guarantee the implementation of the system,reduce the bed / nurse ratio, improve the comprehensive quality of nurses and other measures can be taken to reduce the occurrence of adverse events.