Our primary blood transfusion set opens the package, inserts a bottle needle into the liquid medicine, and the other side has an exhaust pipe, while the general primary transfusion set does not have an additional side tube and a main body. Usually, intravenous infusion is a general infusion set, and surgical patients will use a blood transfusion set, and the exhaust pipe of the blood transfusion set cannot be ignored.

The case is as follows:

The patient Li was hospitalized due to uterine fibroids and required surgery on a certain day. The operation went smoothly. After the operation, he was out of the operating room. Nurse Li, who had just worked for half a year, took the patient and found that the patient's fluid was almost finished dripping. The patient was replaced immediately Last bottle of liquid, but forgot to plug in the vent tube of the blood transfusion set. Fifteen minutes after the operation, Nurse Liu visited the ward and found that the liquid bottle of patient Li was flat. She immediately realized that Nurse Li must have forgotten to plug in the vent. Regardless, Nurse Liu didn’t say anything, and immediately took the disposable syringe** liquid bottle stopper to vent the liquid bottle. The liquid bottle quickly returned to normal. Nurse Liu carefully adjusted the drip rate. The patient and family did not care, but the attention was all on. The patient was on his body, so this incident did not cause any problems or doubts. Although the patient and family members do not pursue this matter, this incident is purely an adverse nursing incident and must be taken seriously. Nurse Liu called to Nurse Li to tell her that she must be careful in the future and that she needs to learn more and be good at observation.

Analysis of the cause of the adverse nursing event

1. Nurse Li lacks clinical experience.

2. The nurses have insufficient knowledge of intravenous infusion pipelines, carelessness, and low technical level.

3. The nurse's safety awareness is weak, and the sense of responsibility is not strong.

Lessons learned and corrective measures

1. The head nurse held a meeting of general nurses, emphasizing the precautions of various nursing operations, and required every junior nurse to understand the principles of safe infusion and the use of infusion sets.

2. Strictly strengthen the training of all nurses' specialized knowledge, especially low-age nurses.

3. Low-senior nurses need to be accompanied by senior nurses during the operation, and guidance is given when necessary, to check for deficiencies and prevent such incidents from happening again.

4. Enhance the sense of responsibility of each nurse and improve the safety awareness of nurses.

5. The head nurse of this department also reviews and consolidates emergency knowledge by asking questions every morning, so as to achieve a proficient grasp of emergency knowledge. It also organized low-age nurses and senior nurses to carry out bedside nursing rounds, and asked each other inspiring questions, so that each nurse mastered nursing and cultivated the nurse's comprehensive and comprehensive observation ability.

In the case, it can be seen that Nurse Li is a low-age nurse who is unfamiliar with the basic infusion and blood transfusion usage. She has insufficient experience, poor personal self-discipline, low sense of responsibility, and unrigorous work attitude. She is not familiar with the progression and outcome of the disease. The prognostic judgment is not strong, the basic knowledge is not well mastered, and the ability to take the initiative to learn is poor. The senior nurse Liu Hong has mastered the emergency response ability of nurses. In clinical nursing work, she has keen observation ability, proficient skills and skills, and calmly handle emergency cases. Therefore, the hospital needs to strengthen the systematization of junior nurses. The emergency response ability training has improved their ability to deal with emergencies.