确保在囊管复制期间的患者安全:通过医疗保健故障模式对设备再处理的风险评估和效应分析
Miriam Roncal Redin1,2,3, Cristina Diaz-Agero Perez4,5,6, Cornelia Bischofberger Valdes4,5
1Hospital Universitario Ramón y Cajal, Ctra. de Colmenar Viejo, km. 9,100, 28034, Madrid, Spain. miriam.roncal@salud.madrid.org.
World journal of urology
|April 30, 2025
概括
灵活的囊镜再处理故障,包括不当的清洁和消毒,构成感染风险. 改善员工培训,设备和可追溯性对于泌尿器科部门的患者安全至关重要.
科学领域:
- 泌尿器科 泌尿器科 泌尿器科 泌尿器科
- 感染控制 感染控制
- 改善医疗保健质量 改善医疗保健质量
背景情况:
- 柔性囊镜是一种常见的泌尿外科手术,具有囊镜污染的重大风险 (2-21%).
- 未被检测到的感染对患者的安全构成威胁,强调需要严格的再处理协议.
- 研究囊囊镜再处理对于提高患者安全和程序效率至关重要.
研究的目的:
- 在第三级医院的泌尿器科详细介绍了囊镜再处理阶段.
- 使用故障模式和影响分析 (FMEA) 识别和量化潜在的系统故障及其相关风险.
- 提出有针对性的改进行动,以提高囊囊镜再处理的安全性和效率.
主要方法:
- 使用故障模式和影响分析 (FMEA) 方法的定性研究.
- 通过直接观察和员工采访收集数据,以映射流程,子流程和潜在的故障模式.
- 根据故障频率,严重程度和可检测性,使用风险优先级号 (RPN) 来量化风险.
主要成果:
- 在囊囊镜再处理中确定了9个过程,11个子过程和16个故障模式.
- 关键故障模式 (RPN>100) 包括不当的手动高级消毒,不充分的清洁 (缺乏刷毛),以及缺乏可追溯性.
- 确定的主要原因是人员培训不足,程序频率高,基础设施不足.
结论:
- 不适当的组织结构和设备在重新处理过程中严重损害了患者的安全.
- 确定了关键的关键故障模式:缺乏可追溯性,清洁不足,手动高级消毒不当.
- 建议的改进措施包括加强员工培训,增加囊囊镜供应,基础设施升级,并优先考虑自动化消毒和可追溯系统.
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