摘要
目的通过手术室护士自愿上报手术物品清点接近失误事件的特征,对相关系统因素进行风险识别与分析,降低手术物品清点风险,预防不良事件的发生。方法本研究为回顾性研究。应用自行设计的手术物品清点接近失误调查表,记录2017年1月至2021年12月山东第一医科大学附属省立医院手术室护士自愿上报的手术物品清点接近失误事件及其特征与原因,应用灰色关联度分析法进行风险因素分析与识别。结果护士共上报98例手术物品清点接近失误事件。清点接近失误手术物品主要分为6类,其中一次性手术物品占52.04%(51/98)、手术器械细微部分占24.49%(24/98)、内植物占14.28%(14/98)、电外科器械占5.10%(5/98)、动力系统占3.06%(3/98)、医用激光占1.02%(1/98);清点接近失误事件发生风险最高的物品种类是一次性手术物品(术者操作不规范ξ1=0.333),9类风险因素中术者操作不规范(r1=0.673)、洗手护士操作不规范(r4=0.691)和术者操作失误(r2=0.693)是最主要的三大影响因素。结论通过分析手术物品清点接近失误产生的系统风险因素,利于护士有针对性地采取风险管理策略,以提升手术物品的清点安全,预防不良事件发生。
Objective To describe the characteristics and analyze risk factors for surgical items count near-miss errors stemming from the self-incident reports of staff nurses from operating room,to reduce the risk of counting surgical items and prevent the occurrence of the relative adverse events.MethodsThis was a retrospective study.Used the self-made checklist to retrospect the surgical items count errors,relative characteristics and reasons from the operating room nurses of Department of Anesthesiology,Shandong Provincial Hospital Affiliated to Shandong First Medical University reported from January 2017 to December 2021.Grey Relational Analysis was used to analyze and identify the risk elements.Results A total of 98 surgical items count near-miss errors were reported by nurses.The unclear items were mainly classified into 6 categories,of which 52.04%(51/98)were disposable surgical items,24.49%(24/98)were fine parts of surgical instruments,14.28%(14/98)were implants,5.10%(5/98)were electrosurgical instruments,3.06%(3/98)were power systems,and 1.02%(1/98)were medical lasers;the disposable surgical items were the highest risk of surgical items count near-miss errors(non-standard behaviors of surgeons 1=0.333);among the 9 risk factors,non-standard behaviors of surgeons(r1=0.673),instrument nurses improper operation(r4=0.691)and surgeons errors(r2=0.693)were the most important influence factors.Conclusions Analyzing the possible system risk factors resulting from the near-miss error could be a useful method for nurses to generate hierarchical risk-control strategies and improve surgical items count safety for patients.This com prerent the occurrence of adverse events.
作者
刘光英
安晓华
徐雯
肖利允
王新
茅金宝
Liu Guangying;An Xiaohua;Xu Wen;Xiao Liyun;Wang Xin;Mao Jinbao(Department of Anesthesiology,East District,Shandong Provincial Hospital Affliated to Shandong First Medical University,Jinan 250021,China;Department First Ward of Anesthesiology,Shandong Provincial Hospital Afiliated to Shandong First Medical University,Jinan 250012,China)
出处
《中国实用护理杂志》
2023年第20期1535-1542,共8页
Chinese Journal of Practical Nursing
基金
山东省医药卫生科技发展计划项目(2019WS471、202014021378)。
关键词
风险因素
手术物品清点
接近失误
灰色关联度分析
预防与整改
Risk factors
Surgical items count
Near-miss error
Grey relational analysis
Prevention and rectification
