2016护理核心制度关键环节管理

488 operative / post op complications ? 385 events relating to medication errors ? 302 deaths related to delay in treatment ? 244 patient falls ? 153 deaths of patients in restraints ? 125 pen natal death / injury ? 94 transfusion-related event ? 85 infection-related events ? 72 deaths following elopement ? 66 fires ? 67 anesthesia-related events ? 51 51 retained foreign objects ? 773 “ other ”= 4074 RCA = 4074 RCA WHO WHO 日本药品事故报道? 1991 :对末期女性? 1999: 误将肺炎及胃癌病人的点滴注射液置错,一人当日死亡,一人两周后死亡。? 1999 :因处方抄写错误,将 10 倍吗啡量用于患者致死亡。? 2000 :护士误将口服用于静点,致 6个月婴儿死亡。? 2000 :安眠药 0.5mg 误为 5mg 致病人中毒昏迷。? 2000 :电脑处方录入错误,将类固醇抗炎药误为肌肉松弛剂致病人死亡。