电子输血安全系统:患者安全事件的描述
Marta Haro1, Susana Ramos2, Teresa Magalhães2
1NOVA National School of Public Health, Public Health Research Centre, NOVA University Lisbon, Lisbon, Portugal.
Portuguese journal of public health
|May 19, 2025
概括
研究了使用条码技术的电子输血安全系统 (ETSS) 的故障. 大多数事件都没有伤害患者,突出了系统.
科学领域:
- 医疗保健信息学 医疗保健信息学
- 患者安全 患者安全
- 临床输血医学 临床输血医学
背景情况:
- 医疗保健系统面临着患者安全方面的挑战,临床错误影响了十分之一的患者.
- 输血过程是复杂的,涉及多个阶段和利益相关者,为潜在的错误提供了关键点.
- 信息技术 (IT) 对于提高医疗机构的患者安全至关重要.
研究的目的:
- 调查使用条码技术的电子输血安全系统 (ETSS) 发生故障的患者安全事件.
- 在医院输血过程中分析关键点和识别故障模式,从储存到患者服药.
- 评估ETSS对患者安全的影响,并确定需要改进的领域.
主要方法:
- 一项为期3年的回顾性研究 (2021-2023),采用混合方法方法.
- 来自里斯本一家医院的136份与"血液和血液制品"有关的匿名事件报告的分析.
- 开展一个由六位专家组成的焦点小组,以收集定性见解.
主要成果:
- 采用条形码技术的ETSS确定了关键点,包括患者识别,重新标记和运输.
- 在样本采集和处方阶段,近乎失误事件的发生率较高.
- 作为人类和技术组成部分的混合系统,ETSS显示,96%的事件不会对患者造成伤害.
结论:
- 该研究强调了IT,特别是基于条形码的ETSS在减轻输血错误和提高患者安全方面的重要性.
- 对IT系统的持续投资和利益相关者的参与对于提高输血过程的安全性至关重要.
- 在ETSS中识别的错误检测和预防机制正在积极运作,有助于患者安全.
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