在手术室减少留存的外来物体:质量改进倡议
Olivia A Keane1, Cindi Chambers1, Colin M Brady1
1From the Department of Surgery, Emory University, Atlanta, GA (Keane, Santore).
Journal of the American College of Surgeons
|August 28, 2023
概括
实施了一项以手术计数为重点的质量改进倡议,在儿科手术中显著减少保留的异物 (RFOs). 这一举措将RFO事件之间的时间从29天增加到451天,提高了患者的安全性.
科学领域:
- 儿科手术 儿科手术
- 患者安全 患者安全
- 提高质量 提高质量
背景情况:
- 留住的外来物体 (RFOs) 是儿科手术中罕见但至关重要的哨兵事件.
- 在2021年,该机构观察到RFOs的增加.
- 该研究旨在通过有针对性的倡议来减少RFO的发生率.
研究的目的:
- 在儿科手术过程中,尽量减少留存异物 (RFOs) 的发生率.
- 为了增加RFO事件之间的间隔.
- 通过质量改进倡议提高患者安全.
主要方法:
- 一个多学科团队开发了一个六步方案,重点关注手术计数,安静时间和沟通.
- 该计划在4个手术中心实施,该中心位于儿童医疗保健系统的第三级医院.
- 七个计划-做-研究-行动周期被用来完善和实施协议,并监测遵守.
主要成果:
- RFO事件之间的平均时间从实施前的29天增加到实施后的451天.
- RFO事件的数量从2021年的7个减少到2022年的0个.
- 在研究结束时,协议的遵守率达到96.4%.
结论:
- 质量改进方法,特别是标准化最终的手术计数,可以有效地减少儿科手术中的RFOs.
- 实施的协议在防止保留的外来物体方面取得了显著的成功.
- 标准化手术计数程序是改善儿科手术环境中患者安全的关键策略.
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