在澳大利亚的外科患者中,导致患者死亡的非技术性错误
Jesse D Ey1, Victoria Kollias1, Octavia Lee1
1Department of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, Woodville, South Australia, Australia.
The British journal of surgery
|April 29, 2025
概括
非技术性错误在手术死亡事故中很常见. 提高决策和情境意识技能对于减少手术死亡至关重要.
科学领域:
- 外科手术的安全性
- 患者的治疗结果.
- 医疗错误分析 医学错误分析
背景情况:
- 非技术技能 (NTS) 对于预防手术不良事件至关重要.
- 改善NTS是优先事项,但有效干预的证据有限.
- 本研究调查了与手术死亡相关的NTS错误,以告知改进策略.
研究的目的:
- 确定与外科手术死亡率相关的非技术错误的发生率和特征.
- 确定外科手术死亡事故中非技术性错误的预测因素.
- 分析随着时间的推移,非技术错误发生率的趋势.
主要方法:
- 从2012年至2019年报告给澳大利亚和新西兰外科死亡率审计 (ANZASM) 的外科死亡病例的回顾性分析.
- 使用经过验证的工具来评估与死亡有关的非技术错误.
- 采用多变量分析和统计过程控制图表来识别预测因素和趋势.
主要成果:
- 在3695例分析的手术死亡事件中,非技术性错误与63.7%的病例有关.
- 决策 (58.4%) 和情境意识 (56.4%) 的错误是最常见的.
- 总体而言,非技术性错误的发生率从2012年至2019年大幅下降,但决策或情境意识错误的发生率并没有显著下降.
结论:
- 非技术性错误对手术死亡率有很大影响.
- 有针对性的NTS改进工作应集中在决策和情境意识上.
- 需要进一步的研究来解决持续的决策和情境意识缺陷.
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