People, refers to the manufacture of products; machine, the equipment used in the manufacture of products; material, refers to the raw materials used in the manufacture of products; method, refers to the methods used in the manufacture of products; ring, refers to the environment in the process of product manufacturing. Want to practically analyze *** work defects and adverse events, improve the quality of work, none can not be from the people, machines, materials, law, the five elements of the ring to find out the reasons and solutions.
One: the "human" factor No one can solve the problem without people or produce the product. Of course, it is also because of human thinking, ideas, skills and many other factors that make the quality of work deviation or even deviation from the standard. But no matter which situation does not show that people in all things in the key role. Therefore, to improve the quality of care, "people" is a key element. Two: "machine" factor "Machine" represents the factors such as equipment - in short, it is our hardware facilities. It's our hardware. If there are no problems with personnel, they are the second thing we think about, because deviations in hardware performance can lead to errors in product quality. Three: "material" factors "Material" - that is, supplies, materials, etc.. Common "material" factors: material (infusion tubes, gastric tubes, sterilization kits and other items, medicines). Analysis perspective: the availability of quantity (enough or not), quality (suitable or not, good or bad) and so on. Such as infusion tube connector packaging backward folding, sterilization labels easy to wear and blur, etc.. Four: "law" factor "Law" - is the method, approach, operating method. Specifically is the operation or work in the process of the work method, whether it is strictly in accordance with the operating guidelines for the operation; not afraid of cumbersome, do not seek shortcuts, do not make things up out of thin air, think so so everything is fine, step by step carefully to do. Five: "ring" factor Common "ring" factor: ring (internal environment, external environment). Analyze the perspective:? Site environment, hardware environment, software environment? Such as the sabbatical meeting site is not fixed, poor conditions of the corridor beds, etc.. Adverse nursing events include: (1) Patient falls, medication errors, wandering, accidental aspiration or choking, burns, and other nursing accidents related to patient safety during hospitalization. (2) Diagnostic or therapeutic errors resulting in medical events such as serious complications, unnatural death, serious functional impairment, prolonged hospitalization, or increased hospitalization costs for the patient. (3) Serious adverse drug reaction or adverse blood transfusion reaction. (4) Damage to patients or medical personnel due to medical devices or medical equipment. (5) Damage to a patient caused by a worker or chaperone. (6) Serious nosocomial infection. (7) Outpatient emergency, defense, information and other related adverse events.