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定义人为错误对外科服务中不良事件的贡献
H Wain1, D L Clarke1,2, S Wall1
1Department of Surgery, University of KwaZulu-Natal, South Africa.
概括
人类错误导致了手术护理中超过一半的不良事件,增加了患者死亡率和住院时间. 多层次干预对于减少这些可能可以避免的医疗错误至关重要.
科学领域:
- 医疗安全 医疗安全
- 外科手术的结果
- 医疗保健的质量 医疗保健的质量
背景情况:
- 评估10年来在南非外科部门对人类错误对不良事件的影响.
- 了解患者护理中的医疗错误的普遍性和类型.
研究的目的:
- 量化人类错误对不良事件的贡献.
- 确定医疗错误的主要来源和趋势.
- 评估错误对患者结果和住院时间的影响.
主要方法:
- 一个外科部门的不良事件数据库的回顾性分析 (2012年12月 - 2023年1月).
- 对不良事件的分类,以识别与错误相关的事件.
- 统计评估错误率,类型,趋势以及对停留时间和死亡率的影响.
主要成果:
- 记录了超过14000次不良事件,其中52.7%与人为错误有关.
- 错误在护理交付 (76%的错误) 和评估 (14%的错误) 中占主导地位.
- 与错误相关的事件显著增加了停留时间和死亡率,尽管在2016-2022年期间观察到错误的下降趋势.
结论:
- 人类错误是超过一半的手术不良事件的重要因素,导致患者的结果更差.
- 错误发生在患者入院的所有阶段,需要全面的,多层次的干预.
- 观察到的错误减少归因于持续的,累积的努力,而不是孤立的干预.
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