超越"从未发生的事件":对正在进行的鼻胃管位置测试事件的定性内容分析
Kate Glen1,2,3, Christine E Weekes2,4, Agi McFarland5
1Nutrition and Dietetics, University College London Hospital, London, UK.
Journal of patient safety
|September 12, 2025
概括
审查鼻胃管 (NGT) 事件显示,由于排位而造成的伤害很少发生,但强调由于程序不一致而造成的延误. 目前的NGT位置测试实践,特别是pH测试,需要重新评估以改善患者护理.
科学领域:
- 患者安全 患者安全
- 改善临床实践的改善
- 医疗器械管理 医疗器械管理
背景情况:
- 医疗保健事件报告系统捕获有价值的数据,以提高质量.
- 鼻胃管 (NGT) 放置确认缺乏标准化,普遍接受的方法,导致实践变化.
- 目前的NGT位置测试方法,包括pH测试,可能存在影响患者护理的限制.
研究的目的:
- 分析与正在进行的鼻胃管 (NGT) 位置测试相关的临床背景和事件的主题.
- 评估NGT位置确认的有效性并确定当前临床实践中需要改进的领域.
主要方法:
- 昆士兰卫生 (澳大利亚) 和英格兰NHS事件报告的定性内容分析.
- 包含和排除标准用于从数据库中过相关事件.
- 多学科团队对提取的事件数据进行审查.
主要成果:
- 在这两个地区,很少有事件符合纳入标准,很少有直接来自NGT流离失所的伤害.
- 确定的主题包括正在进行的NGT位置测试结果 (例如,错过的药物),人员因素,程序不遵守和报告质量差的问题.
- pH测试被认为是不确定的结果的一个因素.
结论:
- 定性分析有效地确定了临床实践主题,尽管事件报告质量变化.
- 虽然流离失所的NGT造成的伤害并不常见,但程序上的不一致性会导致延误,并需要审查当前的做法.
- 对于NGT位置确认的pH测试的依赖需要特别注意和潜在的修订.
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