肠道营养:一个被低估的患者安全事件来源
Sandra Wolfe Citty1, Mary Chew2, Lynn D Hiller3
1Geriatric Research, Education, and Clinical Center, Department of Family and Community Health Systems, North Florida South Georgia Veteran's Health System, University of Florida, College of Nursing, Gainesville, Florida, USA.
概括
肠道营养 (EN) 治疗中的医疗错误很常见. 对1227个安全事件的分析显示,大多数伤害发生在药物管理,监测和发行期间,突出了EN治疗改进的关键领域.
科学领域:
- 患者安全 患者安全
- 改善医疗保健质量 改善医疗保健质量
- 临床营养学 临床营养学
背景情况:
- 肠道营养 (EN) 对无法获得足够口服摄入量的患者至关重要.
- 报道的医疗错误和EN治疗中的临近呼叫导致了患者的伤害.
- 需要系统地分析EN安全事件,以确定改进机会.
研究的目的:
- 量化和分类与肠道营养 (EN) 治疗相关的安全事件.
- 确定因EN相关安全事件造成的伤害的类型和严重程度.
- 提出基于证据的建议,以提高EN治疗的安全性.
主要方法:
- 使用国家患者安全中心 (NCPS) 联合患者安全报告 (JPSR) 系统来检索数据.
- 使用与EN治疗相关的关键词查询相关安全事件的JPSR数据库.
- 使用药物使用过程 (MUP) 框架对事件叙述进行主题分析.
主要成果:
- 确定了1227个与EN治疗关键词相关的安全事件.
- 对1030个事件的分析显示,691个事件与MUP步骤直接相关.
- 主要事件类别包括管理 (31%),监测 (28%) 和发行 (26%).
结论:
- 在EN治疗中经常报告安全事件,导致患者受到伤害.
- 在EN治疗的处方,文档,分发,管理和监测阶段需要改进.
- 在高风险的MUP步骤中进行有针对性的干预可以减轻与EN相关的患者伤害.
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