全球触发工具和反射主题方法分析的高风险手术后死亡之前的事件
Johan Paulander1, Rebecca Ahlstrand2, Erzsébet Bartha1
1Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Huddinge, Sweden.
Acta anaesthesiologica Scandinavica
|October 1, 2024
概括
高风险手术患者由于护理问题而面临死亡. 副作用,特别是在手术当天,以及缺乏关于管理术后风险的共识,导致手术队伍中的死亡.
科学领域:
- 手术结果研究研究.
- 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:
- 术后死亡率是一个关键问题,受到护理质量和及时干预的影响.
- 高风险的手术患者需要警监测和有效的救援策略.
研究的目的:
- 描述在高风险手术患者队列中导致死亡的事件序列.
- 确定与术后死亡率相关的反复出现的主题和不良事件.
主要方法:
- 对手术后30天内死亡的患者的医院记录进行分析.
- 利用叙事主题方法和全球触发工具来识别护理问题和不良事件.
主要成果:
- 确定了九个反复出现的主题,包括在外科目的/风险,手术内能力和术后警方面达成共识的问题.
- 记录了303次不良事件 (AE),其中36%直接导致患者死亡,60%被认为是可以预防的.
- 副作用的发病率高峰发生在手术当天,最常见的是"生命功能失败"和感染.
结论:
- 预测的高死亡风险和手术当天发生的意外事件的激增是这一队伍的特征.
- 缺乏关于管理术后风险,警和术后护理的记录多专业共识是一个重大问题.
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