在麻醉呼吸道管理中探索安全II原则 - - 对webAIRS报告的困难和失败的输入管道进行定性分析
Yasmin Endlich1,2,3, Ellen L Davies4, Janet Kelly2
1School of Medicine, The University of Adelaide, Adelaide, South Australia.
Anaesthesia and intensive care
|March 26, 2025
概括
通过检查没有造成伤害的气道事件,提高了麻醉患者的安全性. 了解麻醉师如何适应意想不到的事件可以提高呼吸道管理的安全性.
科学领域:
- 麻醉学 麻醉学
- 患者安全 患者安全
- 医疗保健管理的管理
背景情况:
- 麻醉呼吸道事故仍然是一个重要的患者安全问题,通常使用传统的安全I原则进行调查.
- 这些方法专注于错误,为防止伤害提供了有限的新见解.
- 向安全II原则的转变为管理复杂的医疗保健事件提供了更广泛的视角.
研究的目的:
- 确定有助于气道管理安全的因素.
- 分析难以或失败的输管事件,而这些事件并没有对患者造成伤害.
- 了解在现实世界中"完成的工作"与"想象中的工作"之间的差异.
主要方法:
- 对129个向webAIRS数据库报告的气道事故 (2016-2022) 的定性内容分析.
- 专注于被归类为"难以输入管"或"输入管失败"而没有患者不良后果的事件.
- 对叙事数据的诱导性分析以确定新出现的主题.
主要成果:
- 大多数报告的事件都涉及对计划程序的偏离.
- 出现了四个关键主题:患者因素,系统因素,个体麻醉师因素和呼吸道管理策略.
- 规避方法和适应策略是常见的,突出了计划和实际实践之间的差异.
结论:
- 安全II原则提供了对空气道管理安全的更全面的理解.
- 认识到人类表现的动态性和适应性对于提高患者安全至关重要.
- 专注于成功管理关键事件,而不仅仅是错误,可以揭示有价值的安全见解.
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