[2014年苍溪职业高级中学宣传.ppt

 2014年急诊不良事件分析 Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd. 主要内容 Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd. 不良事件报告制度 Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd. 处理流程  Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd. Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd. 2014年急诊不良事件总结 Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd. 未造成后果事件 Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd. Company Logo 夜宿客 患者接瓶 私自带液体回家 上厕所跌倒 接药、注射差错 毒麻管理 隐患事件 Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd. 案例：药物不良事件 经过：凌晨，护士将吗啡错误肌注为杜冷丁。 Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd. 原 因 分 析 1 查对制度执行不严 2 主观印象 3 未严格执行药品管理制度 4 疲惫、导致警惕性不高 Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd. 药物不良事件原因分析 人因素 环境因素 物因素 制度因素 上班注意力不集中 先入为主，只看红处方 一人值班 下半夜值班护士疲惫 同属麻醉药、放置一个柜 毒麻药处方颜色相同 未严格执行三查七对 未严格执行双人核对制度 未严格三查七对 药物不良反应 Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd. 2 3 4 1 严格执行三查七对。 夜间一人值班，与医生或患者核对 加强护士的“慎独”意识 夜间值班集中精神，时刻提高警惕 Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd. 1、 2、 3、 4、 毒麻登记本还有待进一步完善 双人核对执行良好 效果评价 该护士未发生类似事件 科室未发生类似事件 Evaluation only. Created wit