摘要目的：将柏拉图分析法应用于临床护理上报的临床案例中，找出案例涉及风险的关键环节：关键年龄、关键时间段、关键疾病谱、关键项目等，实行护理质量前馈控制，确保护理质量与安全。方法建立临床特殊案例、高风险案例、安全隐患案例、突发事件案例数据库，应用柏拉图的“二八”原则找出案例发生的主要因素、主要矛盾、关键危害、关键问题等，为临床护士提供风险分析、风险防范、风险预防等指引，提高护士的安全隐患意识，减少安全隐患。结果2014-2015年收集的207例案例，主要风险涉及年龄段为41～80岁和21～30岁。主要风险涉及疾病谱为神经系统、心血管疾病、手术麻醉相关问题、肾病、癌症、呼吸系统。主要风险涉及时间段为下夜、上下午；主要风险涉及地点为病房、急诊、辅助检查部门、门诊；主要风险涉及项目为病情突变、心理问题、用药安全、仪器安全，其中患者病情突发变化，及时发现抢救心跳、呼吸暂停13例，成功制止患者自杀13例。临床案例实施柏拉图分析法对安全风险识别后，跌倒发生例数、各种管道脱落、皮肤问题、自杀案例等不良事件发生例数由2014年的6、6、7、5例下降为2015年的2、2、2、1例，呈逐年下降趋势。结论柏拉图分析法在临床案例安全风险识别中的应用，能找出案例的主要问题，有重点地改进，提升护理质量与管理效率。

abstractsObjective To apply Plato analysis method to clinical cases which were reported from clinical nursing, finding out the key link of the risks which were related to the cases:the key age, the key period, the key spectrum of disease and the key projects, etc. To carry out the feedforward control of the quality of care, and ensure the quality and safety of nursing. Methods A database were set up including clinical special cases, high-risk cases, security hidden danger cases and emergency cases. The"two eight"principle of Plato analysis method was used to find out the main factors, the principal contradiction, the key hazard and the key problems of the cases, etc. The aim was to provide guidelines of risk analysis, risk prevention and risk aversion for nurses, and improve their consciousness of security hidden danger, and reduce security hidden danger cases. Results The results of 207 cases collected from 2014 to 2015 showed that the main risks involved the age groups were 41-80 years old and 21-30 years old. The major risks involved the spectrum of disease were the nervous system, cardiovascular disease, surgical anesthesia related problems, kidney disease, cancer and respiratory system. The major risks involved the time were the midnight, morning and afternoon. The major risks involved the locations were sickroom, emergency room, auxiliary inspection departments and outpatient. The major risks involved items were disease mutation, psychological problems, medication safety and instrument safety, among the disease mutation, timely discovered, rescued 13 patients with heart and breathing pause, stop 13 patients who attempted suicide. Since the Plato analysis method was applied to identify the security risks of the clinical cases, the number of falling, all kinds of pipe shed, skin problems and suicides were decreased from 6, 6, 7, 5 in 2014 to 2, 2, 2, 1 in 2015, declining trend year by year. Conclusions Applying the Plato analysis method to identify the security risks of the clinical cases which can find out the main problems of cases and improve nursing quality and management efficiency.