手术护理中的判断错误
Katherine M Marsh1, Florence E Turrentine1, Ruyun Jin1
1From the Departments of Surgery (Marsh, Turrentine, Schirmer, Hanks, Davis, Schenk, Jones), University of Virginia, Charlottesville, VA.
Journal of the American College of Surgeons
|January 23, 2024
概括
判断错误会影响手术患者的结果,特定的手术和患者的疾病 (如糖尿病或慢性肺炎) 会增加风险. 缓解这些错误对于改善手术安全和患者护理至关重要.
科学领域:
- 医学错误分析 医学错误分析
- 手术患者的安全.
- 改善医疗保健质量 改善医疗保健质量
背景情况:
- 人类错误在复杂的医疗保健系统中是一个固有的挑战.
- 判断错误对手术患者的结果和伤害的具体影响仍然不完全理解.
研究的目的:
- 调查在患病或死亡的手术患者中判断错误的发生率和影响.
- 确定与判断错误风险增加相关的术前变量.
主要方法:
- 分析美国外科医生学院的NSQIP (2018) 程序从一个机构.
- 检查30天发病率或死亡率的患者判断错误的医疗记录.
- 后勤回归用于识别判断错误的术前风险因素.
主要成果:
- 18% (31/170) 的患病或死亡率较高的手术患者经历了判断错误.
- 判断错误的风险增加与肝胆道手术,胰岛素依赖糖尿病,严重的慢性肺炎和受感染的伤口有关.
- 特定的患者并发症和程序类型与判断错误有显著的联系.
结论:
- 某些手术程序和患者手术前变量会增加判断错误的风险.
- 判断错误被发现会对这个队列中手术患者的结果产生不利影响.
- 建议采取预防,减轻和监测判断错误的策略,以提高手术安全.
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