How to deal with patients' complaints and medical accidents from the perspective of nursing quality defect management?

The management of nursing errors and accidents is very important for the safety of patients. How to reduce or control nursing errors and accidents is an important content and goal of nursing management, and it is also a problem that nursing managers and researchers should actively explore and solve. How to manage errors and accidents depends on people's understanding of the causes of errors. This paper introduces relevant theories and practical experience of some advanced countries, and discusses how to improve the management of errors and accidents in China.

1 Similarities and differences between the concepts of "nursing errors and accidents" at home and abroad

1. 1 Related concepts of nursing errors and accidents in China

Medical (nursing) accident: refers to an accident in which medical institutions and their medical staff violate the laws, administrative regulations, departmental rules, norms and practices of diagnosis, treatment and nursing, resulting in personal injury to patients due to negligence.

Nursing mistakes: mistakes are made in nursing work because of weak sense of responsibility, carelessness, non-compliance with rules and regulations or low technical level, which directly or indirectly affect patients but do not cause serious adverse consequences.

Nursing errors are divided into general errors and serious errors. A common error refers to an error that has no effect on the patient, or has a slight effect on the patient, but has no adverse consequences. Serious mistakes refer to the dereliction of duty or technical negligence of nursing staff, which causes certain pain to patients and prolongs the treatment time.

Shortboard of nursing: In clinical work, the most common phenomenon is that although there is an error in a certain link, it is corrected in time after it is found, which happens to patients (such as the wrong doctor's advice, but it is not implemented). This phenomenon is called short board of nursing.

Nursing defects are often the risk factors of nursing errors, and nursing errors are the risk factors of nursing accidents. Therefore, effective management of nursing errors and defects is an important means to prevent and eliminate nursing accidents.

1.2 foreign-related concepts

There is no completely corresponding concept abroad, but several concepts are closely related to it.

Error: Failure to implement the original correct plan or take incorrect measures to achieve the goal. Mistakes are not always harmful consequences.

Attempted event: some mistakes or abnormal events occurred during medical treatment. Due to intentional or unintentional real-time intervention, the wrong result did not really happen to the patient.

Clinical event: any event that causes injury or may cause injury to patients, visitors or staff, or any event that causes dysfunction, damage or loss of equipment or property, or any event that may cause complaints.

Medical adverse events: refers to accidental injuries or complications that lead to disability, death or prolonged hospitalization due to medical treatment rather than the patient's disease process.

It can be seen that foreign countries refer to errors that do not harm patients, clinical abnormal events that may harm patients due to the mistakes of medical personnel, and attempted negligence, which can be called medical errors. Errors that cause harmful consequences are medical adverse events, which are defined as medical or nursing accidents in China. It is worth noting that the management scope of nursing errors and related contents abroad is greater than that of nursing errors and accidents in China. This is a problem that we should consider in nursing safety management.

2. Theory and practice of foreign error accident management.

2. 1 theoretical basis of nursing error accident management

How to manage errors depends on people's understanding of the causes of errors. Reason, a British psychologist, put forward two different viewpoints, namely, personal method and systematic method.

Personally, mistakes are mainly caused by personal reasons, which are due to psychological obstacles such as forgetting, inattention, lack of enthusiasm, carelessness, negligence and rashness. Therefore, the countermeasures to prevent mistakes are to punish the wrongdoers, such as naming and criticizing, educating, fining, and even threatening to sue, so as to remind the parties and others to be more careful and reduce the occurrence of personal abnormal behavior. According to the systematic view, everyone makes mistakes, even the best employees in the best organizations may make mistakes. The main reason for the error lies in the system problem rather than the abnormal behavior of non-human. These factors include the hidden dangers of repeated mistakes in the work environment and the organizational procedures that lead to these mistakes. When an error occurs, the key is not to investigate who made the error, but to find out what is wrong with the system and why these problems occur. The countermeasure to prevent mistakes is to systematically design the mechanism to prevent mistakes from the perspective of organization and reduce the environment and opportunities for mistakes.

Personal view and systematic view are completely different in the causes and handling methods of errors. Personal opinion focuses on punishing those who make mistakes. It has two main disadvantages. One is to isolate individual mistakes from the problems of the whole system. In fact, few mistakes are entirely caused by personal reasons. If we don't pay attention to the analysis and improvement of system problems, even if the wrong party is punished, the same mistake may happen again. Another drawback is that people who make mistakes may hide many mistakes for fear of being accused or humiliated, which makes relevant departments or managers lose the opportunity to learn from them. Therefore, many high-risk industries, such as civil aviation and nuclear power, have adopted a systematic view of error management. Dr. L, a professor at Harvard School of Public Health and a patient safety expert, pointed out that fear of being punished after making mistakes is the single biggest obstacle to the promotion of patient safety in medical institutions today. In medical institutions, many mistakes occur repeatedly, and the fundamental reason is that there are problems in our management methods.

2-2 Practice of nursing error accident management abroad

2.2. 1 Safety culture based on the concept of error management system. Safety culture is the sum of values, attitudes, concepts, abilities and behaviors of individuals and groups on safety and safety management. Medical institutions should change the traditional culture of "complaining about others" and build a positive safety culture. Positive safety culture includes four aspects: report culture, justice culture, flexibility culture and learning culture. If an organization has a positive safety culture, it will form an atmosphere in the organization where people are willing to report abnormal events and near misses and learn from their mistakes. "Targeting system+non-punitive environment" is an important symbol of advanced safety culture in hospitals. Positive safety culture is the soul of safety management and the decisive factor for the success of safety management.

2.2.2 Reporting system for adverse events or clinical abnormal events. In the United States, Australia and other countries or regions, different types of reporting mechanisms for medical adverse events have been established. It includes internal report and external report; External reports include voluntary reports and involuntary reports. At present, voluntary reporting is strongly advocated. There are many forms of patient safety reports, including network reports, telephone reports and written reports. Journalists can report their own problems or what others see. The voluntary reporting system takes the form of anonymity, and the informants are strictly confidential. The reported information shall not be used as evidence in court proceedings. The relevant departments give encouragement and even rewards to informants. Some areas have established a voluntary reporting system for abnormal events. For example, a hospital's nursing incident reports include adverse drug events reporting system, acupuncture injury reporting system, fall reporting system, pipeline slippage reporting system, unknown fever reporting system and medication abnormality reporting system. The reporting system encourages the collection of all kinds of incident data related to patient safety, and organizes professionals to analyze the reported data, find out the problems, provide feedback to relevant departments and clinics, and provide timely intervention when necessary to reduce the severity of incident consequences.

2.3 Effect of reporting system for adverse events or clinical abnormal events after implementation

Countries or regions that implement the patient safety notification system have greatly increased the number of reports of medical adverse events. For example, after a hospital in the United States implemented this new reporting system, the error reporting rate increased by 60% in the first year. This makes some mistakes hidden under the surface of the tip of the iceberg, which is convenient for analysis and improvement. Voluntary notification system has played an active role in promoting patient safety. For example, the sentinel event reporting project of JCAHO (Joint Commission for Accreditation of American Health Service Organizations) evacuated high-concentration potassium chloride from nurses' treatment rooms, which is easy to cause death. The clinical accident reporting system established by the Australian Patient Safety Foundation reported 280 patients falling in two years. As a response to the fall event, people designed a fall risk assessment table to assess the fall risk of every patient over 65 years old in hospital and take corresponding nursing measures. Therefore, the number of patients with fractures caused by falls in hospitals has decreased significantly.

3 the status quo of nursing error accident management in China

3. 1 error accident registration and reporting system

The management mode of nursing errors in China still follows the relevant provisions of "Hospital Work System and Responsibilities of Hospital Staff" promulgated by the Ministry of Health 1982. The main content is "each department establishes a register of errors and accidents, and I register the process, causes and consequences of errors and accidents in time." The head nurse organizes discussion and summary in time. After an error or accident occurs, relevant personnel of the general department or the whole hospital should be organized to discuss according to its nature and situation, so as to raise awareness, learn lessons, improve work, determine the nature of the accident and put forward handling opinions. Units or individuals that make mistakes or accidents, which fail to report according to regulations and deliberately conceal, shall be punished according to the seriousness of the case when they are discovered by leaders or others afterwards. "The medical (nursing) accident report is mainly based on the provisions of Articles 13 and 14 of the Regulations on Handling Medical Accidents promulgated in September 2002.

It can be seen from the relevant regulations that the reporting of nursing errors or accidents is still mandatory, at least involuntary. The handling of errors is mainly to find out the responsibility and deal with the responsible person or department accordingly. The treatment methods include review, criticism and education, fine, prosecution, demotion, suspension, and even revocation of practice certificate. It is not difficult to see that the principle of handling is to find out the person who made the mistake, find out the size of his responsibility, and criticize and punish the individual or department. Medical staff and medical institutions have to report those incidents that have to be reported for fear of criticism, punishment and exposure. In essence, it belongs to the cultural state of self-blame, and the existing notification system lacks the analysis and utilization of the report materials.

3.2 Relevant regulations of nursing quality control on nursing error accident management.

In the nursing quality management standard, the number of serious nursing errors and nursing accidents in different levels of hospitals is stipulated. For example, the number of serious mistakes per year 100 beds in a top-three hospital does not exceed 0.5 times, and the accident is zero. This obviously focuses on terminal management rather than process management. It is not excluded that in order to meet this standard, the Ministry intends to reduce the number of errors reported. From the perspective of process management, the more errors are exposed, the better. The number of false reports does not represent the safety of patients. Instead, it reflects the advanced level of safety culture.

4. Improvement of management methods of nursing errors and accidents in China.

Reforming traditional culture, paying attention to system perfection rather than individual punishment, and establishing an effective patient safety incident notification system are the direction of nursing error accident management reform.

4. 1 Improve the quality evaluation standard of safety management

Safety management should focus on process management. Formulate effective management methods and implement them. The level of ward safety management cannot be evaluated by the number of error reports.

4.2 methods to improve the management of error accidents

Create an atmosphere in the hospital, everyone attaches importance to patient safety, discusses patient safety, and reduces or exempts the punishment of the parties involved in the accident. This requires hospitals to change from top leaders to clinical staff. The parties concerned may be exempted from punishment for mistakes that have not caused injury consequences or disputes. If a dispute or lawsuit is caused and compensation or compensation is needed, the medical personnel shall bear corresponding responsibilities. All exemptions or all investigations are inappropriate. We have seen some gratifying practices. For example, Zhou Lining introduced the method of analyzing the causes of a nursing mistake from the whole system and taking targeted measures, but this is still partial. In an environment without punishment, people are willing to expose more problems, which is more conducive to solving problems.

4.3 Establish a voluntary reporting system for errors and accidents.

It is the necessary premise and important means of nursing error accident management. In 2006, the Chinese Medical Doctor Association announced the patient safety goal for 2007, which has eight key goals, and the eighth goal is to encourage the active reporting of medical adverse events.

Nursing errors and accidents can be reported by participating in a unified patient safety reporting system organized by the Medical Association, or by establishing a nursing error or accident reporting system organized by the Chinese Nursing Association or the provincial and municipal nursing associations. Hospitals should establish a system for reporting nursing errors and accidents in hospitals. Professionals at all levels analyze the reported errors and accidents, and provide the analysis results to hospital leaders, relevant administrative departments, clinical nurses and other relevant departments in time. At the same time, we should vigorously carry out relevant research.

No matter from the international development or from the requirements of safety management in China, it is imperative to establish a voluntary notification and related analysis mechanism for adverse events. This should not just stay in writing. It is time for nursing managers to take immediate action.