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手术安全不是偶然发生的:从外科手术期间的近乎失踪案例研究中学习
Christopher H Stucky1, J Michael Hartmann2, Young J Yauger3
1Center for Nursing Science and Clinical Inquiry, Landstuhl Regional Medical Center, Landstuhl Kirchberg, Rheinland-Pfalz, Germany.
概括
在手术中,近乎失误,虽然往往没有被注意到,但与不良事件的根本原因是相同的. 分析这些近乎失误的情况为护士提供了重要的学习机会,以提高患者安全并减少医疗保健风险.
科学领域:
- 医疗保健的质量和安全
- 护理实践 护理实践
- 风险管理 风险管理
背景情况:
- 手术后的不良事件会对患者的健康状况产生负面影响,往往会掩盖常规护理.
- 接近失误,虽然比不良事件少见,但更频繁地发生,并具有类似的根本原因和失败模式.
- 识别复杂的外科外科设置的弱点对于减少患者和工作人员医疗保健相关风险至关重要.
研究的目的:
- 为了教育和告知医疗保健专业人员关于外科手术期间的近乎失误事件.
- 激发对医疗错误造成的潜在因素的批判性思考.
- 为护士领导提供案例研究,以加强降低风险的计划.
主要方法:
- 讨论了15个外科手术期间近乎失败的病例研究.
- 分析导致近距离失误事件的因素.
- 探索近距离失误报告的障碍.
主要成果:
- 差点失误为识别和解决患者护理缺点提供了宝贵的学习机会.
- 案例研究说明了常见的失败模式和与不良事件相似的根本原因.
- 确定了报告近距离失误的障碍.
结论:
- 对近乎失误的审查对于护士来说是必不可少的,以开发解决方案并提高患者护理.
- 护士领导可以利用案例研究来促进讨论和实施全面的风险降低策略.
- 了解近乎失误的情况对于改善复杂的外科环境中的安全至关重要.
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