关键词: 病人安全, 安全管理, 护理不良事件

Abstract: Objective To explore the effects of case analysis on nursing adverse events management. Methods
Adverse events in a hospital were classified according to the classification standards of nursing adverse events is
sued by the National Hospital Management Institute. Those adverse nursing events were pooled together and similar
cases from different departments were analyzed every month. Besides，case analysis was conducted every 3 months
at the hospital level. Interventions were proposed to eliminate the risk factors. The incidence of adverse events was
compared before and after the case analysis. Results After the case analysis，the incidence of nursing adverse
events decreased from 0.115% to 0.066%（X2=18.651，P=0.001） . Conclusion Case analysis can effectively reduce the
incidence of nursing adverse events by enhancing the awareness of risk prevention，promoting the improvement of
hospital environment and system process.

Key words: Patient Safety, Safety Management, Nursing adverse events