| 汤丽勇,张培璐.54例非计划拔管事件分析与对策[J].济宁医学院学报,2019,42(1):71-72,76 |
| 54例非计划拔管事件分析与对策 |
| Analysis and countermeasures of 54 cases of unplanned extubation |
| 投稿时间：2019-01-09 |
| DOI：10.3969/j.issn.1000-9760.2019.01.017 |
| 中文关键词: 非计划性拔管;安全管理;护理 |
| 英文关键词: Unplanned extubation;Safety management;Nursing |
| 基金项目: |
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| 中文摘要: |
| 目的 对普通科室54次非计划拔管不良事件进行分析，为保障患者安全及规范管理提供依据。方法 对院内不良系统上报的54例非计划拔管进行回顾性分析，对拔管的类型、班次、科室、原因及事件级别、分类进行分析。结果 54例非计划性拔管事件33例发生于白班，21例发生于夜班；未造成后果事件29例，不良后果事件25例；胃管11例，尿管14例，鼻肠管10例，胸腔闭式引流管8例，深静脉导管3例，负压引流6例，腹腔引流2例；外科较内科多见；拔管的原因主要是患者自行拔除、导管脱落以及导管固定不牢靠。结论 对于非计划性拔管事件，我们应该加强对护理人员的相关培训，做好相关健康宣教，提高护士及患者家属的风险意识是降低非计划性拔管的关键。 |
| 英文摘要: |
| Objective To analyze 54 adverse events of unplanned tubal extubation in general departments,so as to provide the basis for patient safety and standardized management.Methods Retrospective analysis was conducted on 54 cases of unplanned extubation reported by the adverse system in the hospital,and the types,shift,departments,causes,events,levels and characteristics of extubation were analyzed.Results 54 cases of unplanned extubation occurred in day shift.There were 29 cases of non-consequence events and 25 cases of adverse consequence events.Gastric tube was used in 11 cases,urinary tube in 14 cases,nasointestinal tube in ten cases,thoracic closed drainage tube in eight cases,deep vein catheter in three cases,negative pressure drainage in six cases,and abdominal cavity drainage in two cases.Surgery is more common than internal medicine.The main causes of extubation were self-removal and catheter detachment.Conclusion For unplanned extubation,we should strengthen the relevant training for nursing staff,propagate the education forthe public health,and improve the risk awareness of nurses and their families is the key to reduce the unplanned extubation. |
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