杨永洁

[摘要] 目的 探讨在个案分析护理不良事件中改良式鱼骨图的应用效果。 方法 选取2015年9月—2017年9月期间，该院行改良式鱼骨图分析护理不良事件10例，使用改良式鱼骨图对此例不良事件予以详细分析，将其根本原因予以找出，并采取相应措施进行解决。 结果 对于护理不良事件采用改良式鱼骨图进行分析，可将传统鱼骨图存在的缺陷予以弥补，可明确发生护理不良事件的原因，对其一系列工作流程等进行掌握，以及避免护理不良事件发生的措施予以知晓。10例护理不良事件中，有2例给药错误的事件，有3例导管脱落的事件，有3例跌倒的事件，有2例漏开血常规化验单。 结论 使用改良式鱼骨图分析护理不良事件的发生情况，对护理人员予以积极的鼓励，将不良事件予以上报，并对其不良事件进行全面评估，找到问题所在，进而使护理不良事件的发生情况予以降低。

[关键词] 改良式;鱼骨图;护理不良事件;个案分析

[中图分类号] R47          [文献标识码] A          [文章编号] 1674-0742（2018）08（c）-0166-03

Analysis of the Effect of Modified Fishbone Diagram in the Cases of Nursing Adverse Events

YANG Yong-jie

Department of Orthopedics， Laiwu Central Hospital， Xinwen Mining Group， Laiwu， Shandong Province， 271103 China

[Abstract] Objective To investigate the effect of improved fishbone diagrams in the analysis of adverse nursing events. Methods From September 2015 to September 2017， the hospital performed a modified fishbone diagram to analyze 10 cases of adverse nursing events， used a modified fishbone map to analyze this adverse event in detail and to find the root cause， and took corresponding measures to resolve. Results The improved fishbone map analysis was used to analyze the adverse events of nursing care. The defects in traditional fishbone maps can be compensated for. The causes of adverse nursing events can be clearly identified， and a series of workflows can be mastered， and adverse events can be avoided. The measures that occurred were known. Among the 10 cases of adverse nursing events， there were 2 cases of mis-administration， 3 cases of catheter fall-off， 3 cases of falls， and 2 cases of routine blood leakage tests. Conclusion The improved fishbone map was used to analyze the occurrence of adverse nursing events. Nursing personnel were actively encouraged to report the adverse events， and the adverse events were comprehensively evaluated to find out where the problems were， and then the occurrence of adverse care events can be reduced.

[Key words] Improved; Fish bone map; Nursing adverse events; Case analysis

在護理服务中，出现护理不良事件的情况不可避免，当出现护理不良事件的时，护理人员需主动上报，将其情况予以阐述，并对其发生根本予以查询，找到其发生原因，并制动改善措施，让护理人员谨记相关措施和方法，不可在出现同样的事件，此种情况备受相关学者和管理者重视[1-2]。将其原因行图解方式表示，将其发生原因和结果关系行鱼骨图方式显示，将各种原因之间的相互关系予以表明[3]。……