使用全国性事件报告数据库分析手术室中与骨科手术相关的事件
Shiho Nakano1, Toshiaki Kotani2, Arata Nakajima1
1Department of Orthopaedic Surgery, Toho University Sakura Medical Center, 564-1 Shimoshizu, Sakura, Chiba 285-0841, Japan; Department of Rehabilitation, Toho University Sakura Medical Center, 564-1 Shimoshizu, Sakura, Chiba 285-0841, Japan.
概括
骨科手术事件往往涉及经验丰富的外科医生,并导致严重的患者伤害. 关键原因包括未能检查,误判和程序错误,强调需要改进安全协议.
科学领域:
- 医疗安全 医疗安全
- 手术风险管理手术风险管理
- 医疗信息学 医疗信息学
背景情况:
- 在高风险领域,如骨科手术,患者安全至关重要,可预防的不良事件在这些领域很常见.
- 分析手术室事件数据对于提高医疗安全和确定有针对性的干预措施至关重要.
- 这项研究调查了骨科手术事件,以确定严重患者伤害的风险因素.
研究的目的:
- 分析手术室内与骨科手术相关的事件.
- 为了确定与骨科手术中严重伤害相关的危险因素.
- 了解骨科手术事件的原因和严重程度,使用全国数据库.
主要方法:
- 从日本国家事件报告数据库 (2010-2022) 提取了882起与骨科手术有关的事件.
- 分析了患者的人口统计数据,事件时间,手术地点,原因和严重程度.
- 专注于近乎失误和不良事件报告,以确定导致因素.
主要成果:
- 大多数事件涉及具有重要经验的外科医生 (93.3%). 16.0 年).
- 主要原因是非技术性错误:"未能检查" (48.0%) 和"判断错误" (24.0%).
- 86%的事件是严重的,威胁到患者的生命或生计;外科医生的参与增加了严重伤害的风险 (OR: 3.311).
结论:
- 骨科手术事件经常涉及经验丰富的外科医生,并导致严重的患者伤害.
- 诸如"未检查"和"误判"等非技术性错误是造成这些错误的重要因素.
- 整形外科医生必须积极参与安全数据库,以培养报告文化和提高医疗安全.
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