丢失的针头,枕头以及在哪里找到它们
Mingming Zhang1, Min Gao2, Jingwei Wan1
1Department of Neurosurgery, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China.
概括
在神经外科手术中,手术近乎失误事件 (NMI),如丢失的棉花和针头,是常见的. 初级护士和长时间工作等因素增加了NMI风险,突出了需要改善安全性的需要.
科学领域:
- 神经外科 神经外科
- 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:
- 手术"差点失误"事件 (NMI) 对手术室的患者安全构成风险.
- 了解NMI的频率和促成因素对于开发有针对性的干预措施至关重要.
研究的目的:
- 在神经外科环境中评估手术NMI的频率和相关因素.
- 确定NMI中最常涉及的特定项目以及与NMI发生相关的人员和情况的特征.
主要方法:
- 从2019年1月到2022年1月,通过不良事件系统和匿名调查报告的NMI的回顾性分析.
- 使用了包括t测试,皮尔森相关系数和多项逻辑回归模型在内的统计分析.
- 调查的重点是丢失的物品,人员背景和手术条件.
主要成果:
- 总共有195个NMI被确定,棉花 (62) 和针 (133) 是最常见的丢失物品.
- 较小的子和3.0尺寸的针头最常丢失. 在具有初级或非神经外科背景的护士中,NMI更常见.
- 延长工作时间,夜间手术,较大的切口和更多的仪器使用与更高的NMI发病率有关.
结论:
- 神经外科NMI与各种因素有关,包括人员经验和外科条件.
- 报告NMI及其原因对于积极确定预防不良事件的解决方案至关重要.
- 实施基于NMI分析的有针对性的干预措施可以显著提高神经外科手术室的患者安全.
相关概念视频
Line Loss
The different configurations of source-load connections include wye (star) and delta connections. The relationship between line and phase voltages and currents varies depending on the configuration. When the source is supplying power, it is transmitted through the wires to the load, and during this transmission, some power is absorbed by the wires, leading to line loss.
Line loss impacts power delivery efficiency in a balanced three-phase circuit. The symmetry in such a circuit simplifies the...
Line loss impacts power delivery efficiency in a balanced three-phase circuit. The symmetry in such a circuit simplifies the...
Distance Measurements by Taping
Tapes are essential in surveying for accurate, durable, and short-distance measurements. Made from lightweight, nylon-coated steel, they offer flexibility and strength for rugged outdoor use. The nylon coating protects against rust and wear, extending the tape's life. Standard lengths, around 30 meters, are marked in meters and millimeters for precision.Surveyors select tapes based on site conditions and accuracy needs. Lightweight, nylon-coated tapes are commonly used for ease of handling and...
Errors in Taping
Errors in taping arise from multiple factors that can significantly impact measurement accuracy in surveying. Misalignment of the tape, often due to human error, is one primary source. A skilled rear tapeman, using a telescope, can help correct alignment by guiding the head tapeman; however, human limitations still lead to small inaccuracies. These errors may include misplacement of pins or inaccurate tape readings due to common visual confusions, such as mistaking a six for a nine. Such...
Minor Losses in Pipes
In pipe systems, minor losses refer to energy losses arising from components such as valves, bends, fittings, expansions, and other features that disrupt the steady flow of fluid. These disturbances cause energy dissipation through turbulence and resistance, which engineers quantify to manage system efficiency effectively.
Valves play a significant role in generating minor losses by obstructing or redirecting the fluid flow. When a valve is closed or partially closed, it restricts the flow...
Valves play a significant role in generating minor losses by obstructing or redirecting the fluid flow. When a valve is closed or partially closed, it restricts the flow...
Forgetting
Forgetting is an intrinsic aspect of human memory, characterized by the gradual loss or inaccessibility of information over time. Hermann Ebbinghaus, a pioneering psychologist, extensively studied this phenomenon and formulated the forgetting curve. This curve illustrates that memory loss occurs rapidly immediately after learning and then decelerates over time. Several mechanisms contribute to forgetting, including encoding failure, storage decay, retrieval failure, and interference.
Encoding...
Encoding...
Tip-of-the-Tongue Phenomenon
The tip-of-the-tongue (TOT) phenomenon is a cognitive experience characterized by a temporary inability to retrieve specific information from memory despite having a strong feeling of knowing the information. Although individuals cannot access the target word or detail, they frequently recall related elements, such as its initial letter, syllable count, or context. This partial retrieval often causes frustration, as one might recognize a familiar face or know that a name starts with a specific...


