中国典型病例大全

目的 探究护理不良事件管理中质量控制图应用能否实现持续质量改进的目标。方法 对2020—2022年江门市中心医院护理系统上报的医院护理不良事件进行回顾性分析，制作质量控制图，运用正态分布质量控制图计算院内护理不良事件上报率范围，对2023年护理不良事件上报情况进行实时预警监测，反馈指导2024年临床护理不良事件管理。结果 质量控制图客观地反映出不良事件数的分布，针对性改进后，2024年护理不良事件发生率较2023年明显降低。结论 在护理不良事件管理中，运用质量控制图能够设定预警控制限，便于对护理不良事件的实时监控与分析，有望能减少不良事件发生，推动临床护理质量提升。

Objective To explore whether the application of quality control chart in nursing adverse event management can achieve the goal of continuous quality improvement. Methods The adverse nursing events reported by the Jiangmen Central Hospital nursing system from 2020 to 2022 were retrospectively analyzed, the quality control chart was prepared, and the reporting rate range of adverse nursing events in hospital was calculated by using the normal distribution quality control chart, and the reporting of adverse nursing events in 2023 was carried out real-time early warning and monitoring, and feedback and guidance were provided for the management of clinical nursing adverse events in 2024. Results The quality control chart objectively reflected the distribution of adverse events. After targeted improvement, the incidence of adverse events in 2024 was significantly lower than that in 2023. Conclusion In the management of nursing adverse events, the application of quality control chart can set the early warning control limit, facilitate the real-time monitoring and analysis of nursing adverse events, and is expected to reduce the occurrence of adverse events and promote the improvement of clinical nursing quality.