与高流量鼻治疗相关的不良事件的安全性分析:使用日本国家不良事件数据库进行的回顾性研究
Keizo Wauchi1, Sho Tomisaki2, Hirohito Imada3
1Department of Medical Technology, Faculty of Fukuoka Medical Technology, Teikyo University, Omuta City, Japan.
The International journal of risk & safety in medicine
|October 16, 2025
概括
这项研究分析了高流量鼻腔管 (HFNC) 治疗事件,发现患者和管理因素增加了伤害风险. 提高HFNC的安全性需要通过教育和系统变化来解决人为错误和设备问题.
科学领域:
- 医疗安全 医疗安全
- 呼吸系统疗法 呼吸系统疗法
- 医疗信息学 医疗信息学
背景情况:
- 高流量鼻腔管 (HFNC) 治疗被广泛使用,但与潜在的风险相关.
- 分析事件和事故报告对于确定安全改进机会至关重要.
研究的目的:
- 从JCQHC数据库中提取和分析与HFNC相关的事件和事故报告.
- 使用P-mSHEL模型识别导致HFNC事件和事故的因素.
- 为提高HFNC治疗的安全性提供见解.
主要方法:
- 从 94,069 起事件和 56,783 起事故报告 (2010-2023) 中检索了 170 起与 HFNC 相关的案件 (131 起事件, 39 起事故).
- 将定性数据分类为P-mSHEL (患者,管理,软件,硬件,环境,现场软件) 类别.
- 使用后勤回归来分析事故案例中的后果.
主要成果:
- 患者 (P) 和管理人员 (m) 的因素与事故病例的后果有显著的相关性 (OR=2.65,p=0.006;OR=2.46,p=0.033).
- 现场软件 (L - 人类错误) 和硬件 (H - 医疗器械) 分别涉及80.2%和52.7%的事件报告.
- 强调了人类和设备相关因素在HFNC事件中的关键作用.
结论:
- 降低HFNC安全的风险应通过查和组织改进来针对患者和管理因素.
- 由于Liveware和硬件因素的高度参与,结构化的教育和实际的设备干预是必要的.
- 为了确保安全的HFNC治疗,全面的战略是必不可少的.
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