对不良事件报告的系统分析表明,新生儿病房需要改进
Maria Karjalainen1,2, Leena Taittonen1,2, Heini Huhtala3
1Department of Paediatrics, Wellbeing Services County of Pirkanmaa, Tampere, Finland.
Acta paediatrica (Oslo, Norway : 1992)
|July 24, 2023
概括
在新生儿重症监护室 (NICU) 分析不良事件报告,发现了药物错误,并强调了需要改进方案的必要性. 这些数据可以帮助预防未来的不良事件.
科学领域:
- 新生儿重症监护室 (NICU) 的安全.
- 改善医疗保健质量 改善医疗保健质量
- 患者安全研究 患者安全研究
背景情况:
- 新生儿重症监护室 (NICU) 的不良事件对脆弱的婴儿构成重大风险.
- 了解这些事件的模式和原因对于制定有效的预防策略至关重要.
研究的目的:
- 描述NICU环境中的不良事件报告.
- 确定预防反复发生的不良事件的建议.
- 为了检测在非办公时间和假期期间事件的潜在增加.
主要方法:
- 从坦佩雷大学医院的NICU (2013-2020) 报告的925个不良事件的回顾性分析.
- 事件按类型,报告人员 (护士与医生) 和时间的分类.
- 对预防事故的建议干预措施的审查.
主要成果:
- 药物,液体和血液产品管理错误占事件的36.3%,其中34.8%是管理错误.
- 护士报告了89.5%的事件;护士 (35.3%) 比医生 (21.6%) 更常见的近乎失误.
- 在日班,周四,周六以及6月,11月和12月期间观察到更高的事件率.
结论:
- 对不良事件报告的分析对于确定需要在NICU加强协议的领域至关重要.
- 基于事件数据实施有针对性的干预措施可以提高患者的安全性.
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