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Updated: Jul 15, 2025

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在单一中心质量改进审计中识别肠道营养错误
Elise Schwarz1, Olivia Nass1,2, Vanessa Giocondo1,3
1Nutrition Services Department, Froedtert Hospital, Milwaukee, Wisconsin, USA.
概括
肠道营养 (EN) 管理的错误率很高,在标签和执行方面经常出现问题. 这些错误往往未得到报告,这表明需要改进诸如条形码等流程.
科学领域:
- 临床营养学 临床营养学
- 患者安全 患者安全
- 改善医疗保健质量 改善医疗保健质量
背景情况:
- 肠道营养 (EN) 治疗是一个复杂的,多步骤的过程.
- 人类错误在EN治疗中很常见,但在现有文献中定义不佳.
- 审计EN管理实践对于识别执行错误至关重要.
研究的目的:
- 审计EN的管理实践.
- 量化EN执行和文档中的错误.
- 识别经常被错误标记,错误管理或错误记录的EN命令的特定组件.
主要方法:
- 在两天内收集住院患者的EN订单的前性数据.
- 收集的信息包括配方细节,悬挂时间,输液速率和模块化文档.
- 错误被定义为EN命令及其执行/文档之间的不匹配.
- 与一个月报告的与EN相关的安全事件的比较.
主要成果:
- 在160名患者的1045个数据点中,共发现了275个错误.
- 常见的错误包括超过48小时的悬挂时间 (85%),模块化的错误文档 (48%) 和错误的输液率 (19%).
- 在发现的错误和报告的安全事件之间发现了显著的差异,只有一个事件被记录下来.
结论:
- 在EN订单执行和文档中存在相当大的错误率 (15.9%).
- 遵守48小时悬挂时间文档的遵守率很低,为14%.
- 与EN相关的安全事件可能被严重低估,突出了改善过程的机会,例如实施EN条形码.
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