在外科手术中通过食道发声心脏成像时发生的阳性损伤:对医疗设备存储的影响
概括
实施转食管回声心脏图 (TEE) 探针维护的根本原因分析和行动 (RCA2) 显著减少了设备故障. 这通过确保适当的TEE探头存储和处理,提高了心脏麻醉治疗期间的患者安全.
科学领域:
- 麻醉学 麻醉学
- 医疗器械安全 医疗器械安全
- 提高质量 提高质量
背景情况:
- 医疗设备的故障是一个重要的,往往被忽视的,造成阳性损伤的原因.
- 过食管回声心电图 (TEE) 探针问题可能导致心脏麻醉期间患者受到伤害.
- 一个强大的根本原因分析和行动 (RCA2) 框架对于提高患者安全至关重要.
研究的目的:
- 进行RCA2以识别和解决TEE探头故障的原因.
- 实施一个纠正行动计划,以改善TEE探头维护合规性.
- 为了降低心脏麻醉期间与TEE探头故障相关的患者风险.
主要方法:
- 一个多学科团队在与TEE探头插入相关的阳性损伤后进行了RCA2.
- 用鱼骨图和Gemba步行来确定导致的因素.
- 一个纠正行动计划包括购买更大的储存柜,员工教育,并建立标准的操作程序.
主要成果:
- 在研究期间 (2016年7月至2021年6月),TEE探针需要维护51次.
- 干预后,季度TEE探头维护从4.4降至1.0,这是统计学上显著的减少 (p=0.0006).
- 大多数维护 (78.4%) 发生在改进的存储解决方案实施之前.
结论:
- 一个广泛的RCA2专注于TEE探头存储的制造商建议,有效地减少了维护需求.
- 通过更好地遵守存储协议,导致TEE探测器故障较少.
- 这种干预成功地降低了心脏麻醉期间患者受益性损伤的风险.
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