保留的中央静脉导管导线:采访了犯错误的临床医生
Maryanne Z A Mariyaselvam1, Alfie A C Wright2, Peter J Young3
1Lucy Cavendish College, University of Cambridge, Cambridge.
Journal of patient safety
|August 8, 2025
概括
中心静脉导管整个导线的保留是可以预防的患者安全事故. 当前的政策未能防止这种错误,突出了工程安全机制的需要.
科学领域:
- 患者安全 患者安全
- 医疗器械并发症 医疗器械并发症
- 临床错误分析分析
背景情况:
- 中枢静脉导管 (CVC) 整个导线保留是一个严重的,可预防的患者安全事故.
- 并发症包括导线迁移,可能导致心脏穿孔和栓塞.
- 尽管有国家政策,但这种错误仍然存在,这表明目前的预防策略存在差距.
研究的目的:
- 为了澄清中央静脉导管整个导线保留错误的精确机制.
- 确定导致这种患者安全事故的因素.
- 为制定更有效的预防策略提供信息.
主要方法:
- 与10名经历过导线保留错误的临床医生进行了半结构面试.
- 参与者被问及错误的情况,并引入了安全机制.
- 诱导性主题分析被用来分析采访成绩单,并确定有助于因素.
主要成果:
- 导线保留错误发生在不同的临床医生经验水平,患者复杂性和环境条件中.
- 经常报告中断和干扰,特别是在关键的导线拆除阶段.
- 现有的安全检查表明有效性较低,在48次保留确认中,只有4次成功.
结论:
- 整个导线的保留发生在大约1:1167个程序的速度.
- 目前的培训和政策不足以始终防止导线保持,严重依赖于完美的人类表现.
- 需要安全工程机制来防止导线保留,独立于临床环境,分心或临床医生的记忆.
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