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[1]于漫李苗苗王宇袁彬彬张庆伟王蕾.护理隐性安全事件触发因素的质性研究[J].中国卫生质量管理,2026,33(8):53-58.[doi:10.13912/j.cnki.chqm.2026.33.8.11]
　YU Man,LI Miaomiao,WANG Yu.A Qualitative Study on the Triggering Factors of Latent Nursing Safety Incidents[J].Chinese Health Quality Management,2026,33(8):53-58.[doi:10.13912/j.cnki.chqm.2026.33.8.11]

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护理隐性安全事件触发因素的质性研究

《中国卫生质量管理》[ISSN:1006-7515/CN:CN 61-1283/R] 卷: 33 期数: 2026年8期页码: 53-58 栏目: 护理质量出版日期: 2026-08-15

Title:: A Qualitative Study on the Triggering Factors of Latent Nursing Safety Incidents

作者:: 于漫李苗苗王宇袁彬彬张庆伟王蕾; 阜外华中心血管病医院

Author(s):: YU Man; LI Miaomiao; WANG Yu; Fuwai Central China Cardiovascular Hospital

关键词:: 护理隐性安全事件; 护理不良事件; 触发因素; 护理风险管理; 患者安全; 扎根理论

Keywords:: Latent Nursing Safety Incident; Nursing Adverse Event; Triggering Factor; Nursing Risk Management; Patient Safety; Grounded Theory

分类号:: R47

DOI:: 10.13912/j.cnki.chqm.2026.33.8.11

文献标志码:: A

摘要:: 目的探索护理隐性安全事件的触发因素，为护理管理者主动采取风险防控策略提供参考。方法纳入河南省某三级甲等医院上报的368例护理不良事件作为资料，采用程序化扎根理论研究方法，通过三级编码逐步提炼护理隐性安全事件触发因素的初始概念、范畴、主范畴、核心范畴，并构建作用机制模型。结果共提炼出风险预知能力、安全引导力度、多主体特征、隐性护理行为、服务协调管理和设施设备配置6个主范畴，以及预警防控力度、人员行为决策、服务资源配置3个核心范畴，据此构建护理隐性安全事件的触发因素作用机制模型。结论护理隐性安全事件的发生是一个复杂且动态的过程，因素众多且相互关联。当预警防控力度不足、人员行为决策偏差及服务资源配置不当时，潜在风险易引发护理隐性安全事件。

Abstract:: ObjectiveTo explore the triggering factors of latent nursing safety incidents, so as to provide references for nursing managers to proactively adopt risk prevention and control strategies.MethodsA total of 368 reported nursing safety adverse events from a tertiary Class A hospital in Henan Province were included as research materials. The procedural grounded theory method was adopted to gradually extract initial concepts, categories and main categories of triggering factors for latent nursing safety incidents through three-level coding, and construct an action mechanism model.Results6 main categories including risk perception capability, safety guidance intensity, multi-subject characteristics, latent nursing behaviors, service coordination management and facility & equipment allocation were extracted, along with 3 core categories of early warning and prevention intensity, personnel behavior decision-making, and service resource allocation. Based on these, the action mechanism model of triggering factors for latent nursing safety incidents was constructed.Conclusion The occurrence of latent nursing safety incidents is a complex and dynamic process with numerous interrelated factors. When the early warning and prevention intensity is insufficient, personnel behavior decision-making deviates, and service resource allocation is improper, potential risks are likely to induce latent nursing safety incidents.

参考文献/References:

［1］国家卫生健康委办公厅.患者安全专项行动方案 (2023-2025 年)：国卫办医政发〔2023〕13号［EB/OL］.(2023-09-27)［2025-07-11］.http://www.nhc.gov.cn/yzygj/s3586/202310/e72c5c41986a4e5c9e6f a77fd37dd51b.shtml.［2］World Health Organization. Global Patient Safety Action Plan 2021-2030［EB/OL］. (2021-08-03)［2025-06-22］. https://test-cms.who.int/publications/i/item/9789240032705.［3］国家卫生健康委.《2023 年国家医疗质量安全改进目标》解读：国卫办医政函〔2023〕45号［EB/OL］.（2023-02-28）［2025-10-02］.http://www.nhc.gov.cn/yzygj/s3586/202302/573156309e0c4e988115 b80cac8865a5.shtml.［4］李春雷,申占科.社会公共事件中隐性风险的治理：基于W村的田野研究［J］.现代传播(中国传媒大学学报),2026,48(1):57-66.［5］World Health Organization.Patient safety［EB/OL］.(2023-09-11)［2025-09-20］.https://www.who.int/news-room/fact-sheets/detail/patient-safety.［6］卢琪琪,许苹,蔡雅荣,等.护理不良事件分析与对策研究［J］.中国卫生质量管理,2024,31(11):52-55.［7］GOMEZ-MORENO C,VELEZ-VELEZ E,RAMON MG,et al.Patient safety in surgical settings:a study on the challenges and improvement strategies in adverse event reporting from a nursing perspective［J］. J Clin Nurs,2024, 33(6):2324-2336.［8］周洋,王澜,王项南,等.基于冰山理论构建医养结合背景下老年照护岗位胜任力特征模型［J］.护理学报,2023,30(22):30-35.［9］贾旭东,衡量.扎根理论的“丛林”、过往与进路［J］.科研管理,2020,41(5):151-163.［10］CHOI J,LEE S,PARK E, et al.Congruency and its related factors between patients’ fall risk perception and nurses’ fall risk assessment in acute care hospitals［J］.J Nurs Scholarsh, 2024, 56(4): 507-516.［11］WANG YN,YAN P,YOU SP, et al. mHealth-based educational needs in older adults with declines in intrinsic capacity: a qualitative research study［J］. Geriatr Nurs, 2025, 66: 103577.［12］刘彤,肖明朝,赵庆华.国际患者安全发展趋势分析及对我国的启示［J］.中国卫生质量管理,2023,30(9):1-5.［13］石珂,亓秀梅,盛春红,等.触发工具用于护理不良事件监测的范围综述［J］.护理学杂志,2024,39(19):106-110.［14］席祖洋,魏永婷,李茶香,等.基于护理诊断的临床护理计划决策支持系统的研发与应用［J］.中华护理杂志,2025,60(20):2458-2464.［15］王文丽,张艳丽,王超滨,等.我国医疗质量安全不良事件数据分析［J］.中国医院,2025,29(1):25-28.［16］姜璐.大数据背景下医院护理安全风险管理与策略——评《护理安全管理：不良事件案例分析》［J］.中国安全科学学报,2024,34(3):252.［17］王春妮,黄欢欢,彭颖,等.心理账户视角下患者参与患者安全决策行为的成因分析及对策［J］.中国卫生质量管理,2025,32(9):22-26.［18］KELLOGG KM, PUTHUMANA JS, FONG A, et al. Understanding the types and effects of clinical interruptions and distractions recorded in a multihospital patient safety reporting system［J］. J Patient Saf, 2021, 17(8): e1394-e1400.［19］APPIAH EO,OTI-BOADI E,ANI-AMPONSAH M,et al.Barriers to nurses’ therapeutic communication practices in a district hospital in Ghana［J］. BMC Nurs, 2023, 22(1): 35.［20］熊昌娥,陈汇汇,张明,等.医院质量评价指标体系研究现状及进展［J］.中国医院管理,2024,44(3):32-38.

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更新日期/Last Update: 2026-08-15