外腔室排水错误管理事件:系统文献审查和案例报告
Arevik Abramyan1, Evgenii Belykh, Patel Ruchi
1Department of Neurosurgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA.
Operative neurosurgery (Hagerstown, Md.)
|December 3, 2024
概括
药物错误进入外腔室排水管 (EVD) 是可以预防的. 实施新的ISO标准神经轴连接器,如NRFit®,可以显著减少这些关键的神经外科安全风险.
科学领域:
- 神经外科 神经外科
- 患者安全 患者安全
- 医疗器械标准 医疗器械标准
背景情况:
- 外腔室排水 (EVD) 在神经外科手术中至关重要,但存在错位和感染等风险.
- 一个关键的,但较少讨论的并发症是错误地将药物或液体输入EVD系统.
- 本次审查侧重于EVD的管理不当和预防策略,包括新的连接器标准.
研究的目的:
- 审查现有的关于药物错误给EVDs的文献.
- 为了呈现一种血液产品错误输入EVD的案例.
- 讨论促成因素和推安全措施,强调ISO 80369标准.
主要方法:
- 对PubMed,Embase和SCOPUS数据库的系统文献审查.
- 关于错误地将血液产品注入EVD的案例报告.
- 分析导致因素,相关指导方针和建议的预防策略.
主要成果:
- 鉴定了8例错误的药物管理,包括对比剂,麻醉剂和抗药.
- 报告了第一次输血错误输入EVD的病例,导致患者死亡.
- 导致的因素包括系统不熟悉,连接器相似性和可见性差.
结论:
- 错误地注入EVD连接器是可以预防的患者安全问题.
- 建议采用ISO标准的神经轴连接器 (例如NRFit®),以防止错误连接.
- 加强培训和明确的设备标记对于降低风险至关重要.
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