手术中心不良事件报告的频率和内容分析:一个横截面研究
Ítalo Lennon Sales de Almeida1, Ana Paula Agostinho Alencar1, Vanessa de Brito Poveda2
1Universidade Estadual do Ceará. Fortaleza, Ceará, Brazil.
Revista brasileira de enfermagem
|March 19, 2025
概括
手术中心经常报告诸如压力损伤和手术错误等不良事件. 然而,报告不足和记录质量不佳限制了对手术环境中患者安全的理解.
科学领域:
- 医疗安全 医疗安全
- 外科手术的结果
- 改善医疗保健质量 改善医疗保健质量
背景情况:
- 手术中心的不良事件对患者安全构成重大风险.
- 准确报告和分析这些事件对于改善外科护理至关重要.
- 现有数据表明,在不良事件文档中,可能存在报告不足和质量问题.
研究的目的:
- 为了确定手术中心内的不良事件的发生率.
- 分析不良事件报告的定性内容.
- 确定外科手术不良事件的常见类型和贡献因素.
主要方法:
- 进行了一项横截面研究,分析了2019年1月至2023年3月期间来自八家医院的163份报告.
- 定量分析侧重于损害的类型和严重程度.
- 定性分析使用Iramuteq进行报告内容的相似性分析.
主要成果:
- 确定了16个"从未发生的事件",包括严重的压力损伤,错位的活检,错位的手术和保留的异物.
- 通常报告的事件包括压力损伤,烧伤,器官损伤和手术部位感染.
- 定性分析揭示了诸如"护理失败"",外科手术"和"压力损伤"等反复出现的主题.
结论:
- 压力损伤,烧伤,器官损伤和手术部位感染是手术环境中普遍存在的不良事件.
- 在手术中心,不良事件的报道显著不足.
- 记录质量的局限性,包括未指定的事件和缺乏标准化的报告,阻碍了全面的分析和改进工作.
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