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系统性风险分析和缓解策略对于干预性手术室护理中的近乎事故事件
Ling-Yu Ma1, Rong-Fang Shan1, Yong Lu1
1Department of Operating Room, Affiliated Hospital 2 of Nantong University, Nantong, 226001, People's Republic of China.
Risk management and healthcare policy
|January 23, 2025
概括
术内护理近乎失误事件,特别是药物错误,如气栓塞,在干预性手术室中存在重大风险. 改善护士协调和沟通是缓解这些事件和提高患者安全的关键.
科学领域:
- 在外科手术期间的护理.
- 患者安全 患者安全
- 风险管理 风险管理
背景情况:
- 内科护理近乎失误事件是潜在患者伤害的关键指标.
- 了解干预性手术室 (IOR) 中的这些事件对于提高护理质量至关重要.
研究的目的:
- 在IOR中描述手术内护理近乎失误事件.
- 系统地识别和分析相关风险.
- 为这些事件提出有效的缓解策略.
主要方法:
- 一项回顾性研究分析了2023年1月至2024年3月期间报告的81起近乎失误事件.
- 一项专门的调查被用来收集有关IORs的护理近乎失误事件的数据.
- 灰色关系分析确定并排列了与这些事件相关的风险因素.
主要成果:
- 药物错误 (60.49%) 是最常见的近乎失误事件,气栓塞在压力液体的管理被确定为最高风险.
- 其他事件包括耗材,管道,样本处理和患者运输等问题.
- 关键的风险因素包括护士协调不佳,操作中断和职业能力不足.
结论:
- 药物错误,特别是气栓塞,是IOR的主要问题.
- 操作中断和护理能力显著影响了近乎失误事件的发生.
- 加强近乎失误事件的识别和管理对于减少不良外科手术结果至关重要.
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