Retrospective Analysis and Quality Improvement Research of 25 Nursing Adverse Events

Abstract

Objective: To analyze the occurrence characteristics and causes of nursing adverse events in the whole hospital from April 1, 2025 to June 30, 2025, formulate targeted rectification measures, and improve the quality of nursing safety management. Methods: A retrospective analysis method was adopted to statistically analyze 25 nursing adverse events reported by 18 clinical departments in the whole hospital from April to June 2025, and a systematic analysis was carried out from the dimensions of event type, department distribution, grading, occurrence time and causes. Results: Falls/falls from bed accounted for the highest proportion (40.00%, 10 cases), followed by unplanned extubation (16.00%, 4 cases), other events (12.00%, 3 cases), drug-related events (8.00%, 2 cases), and scald events (8.00%, 2 cases). Blood transfusion events, accidental injury events, and medication error events each accounted for 1 case (4.00% respectively). The Geriatrics Department had the highest incidence rate (12.00%, 3 cases). The event grading was mainly Grade Ⅲ (56.00%, 14 cases), followed by Grade Ⅱ (24.00%, 6 cases) and Grade Ⅳ (20.00%, 5 cases). Falls/falls from bed mainly occurred from 22:00 to 8:00 the next day (80.00%), and the patients were mainly elderly people over 65 years old (90.00%). Conclusion: Falls/falls from bed are core risk events, and their causes involve multiple factors including patients, diseases, nurses, caregivers and the environment. It is necessary to construct a closed-loop quality improvement system through comprehensive measures such as strengthening dynamic risk assessment, standardizing nursing operations, optimizing health education, improving environmental facilities and strengthening caregiver management, so as to ensure the safety of patient care.