预防围术期用药错误要从哪里着手?

2020
07/13

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预防围术期用药错误要从哪里着手?

33261594508641174

手术室用药的系统论过程分析

背景:

虽然手术室中用药中有4-10%的几率存在错误,但很少有研究前瞻性地模拟这些错误是如何发生的。系统论过程分析是一种应用系统理论识别危险源的前瞻性风险分析技术。本研究的目的是证明系统论过程分析应用于医疗机构中可以前瞻性地识别手术室用药错误的原因。

方法:

本文作者对他们医院手术室用药进行系统论过程分析。首先,作者定义了与药物相关的事故(不良药物事件)和危害,并创建了一个分层控制结构(手术室药物使用系统的示意图)。然后作者结合外科医生、麻醉医师和药剂师的意见,分析了这种结构的不安全控制行为和可能导致药物错误的因果情景。作者研究了整个药物使用过程,包括申请药物、配药、准备、给药、记录和监测患者的效果。结果采用描述性统计方法报告。

结果:

分层控制结构包括三个层次的控制者:围手术期领导;主治麻醉医师、外科医生和药剂师共同进行的病人护理管理;手术室中麻醉临床医生执行病人护理。作者发现66个不安全的控制措施与342个可能导致药物错误的因果场景有关。82个(24.0%)的情景来自围手术期领导,103个(30.1%)来自病人护理管理,157个(45.9%)来自病人护理的执行。

结论:

在这项研究中,作者展示了系统论过程分析方法来描述手术室用药过程中潜在的错误原因。从一线供应商到最高级别的围手术期管理人员,都与结果关系密切。系统论过程分析是唯一能够分析管理和领导对系统的影响,使其有助于指导质量改进计划。

关于本主题我们已经知道的:

手术室中的用药错误是常见的。公共系统论过程分析是一种前瞻性的工程建模技术,它使用系统理论来识别危险。

这篇文章告诉我们的是新的:

系统论过程分析确定了与结果相关的不安全控制行为。可能导致用药错误的情景来自围手术期的领导、病人护理的管理和病人护理的执行。

A Systems Theoretic Process Analysis of the Medication Use Process in the Operating Room

Background: 

While 4 to 10% of medications administered in the operating room may involve an error, few investigations have prospectively modeled how these errors might occur. Systems theoretic process analysis is a prospective risk analysis technique that uses systems theory to identify hazards. The purpose of this study was to demonstrate the use of systems theoretic process analysis in a healthcare organization to prospectively identify causal factors for medication errors in the operating room.

Methods: 

The authors completed a systems theoretic process analysis for the medication use process in the operating room at their institution. First, the authors defined medication-related accidents (adverse medication events) and hazards and created a hierarchical control structure (a schematic representation of the operating room medication use system). Then the authors analyzed this structure for unsafe control actions and causal scenarios that could lead to medication errors, incorporating input from surgeons, anesthesiologists, and pharmacists. The authors studied the entire medication use process, including requesting medications, dispensing, preparing, administering, documenting, and monitoring patients for the effects. Results were reported using descriptive statistics.

Results: 

The hierarchical control structure involved three tiers of controllers: perioperative leadership; management of patient care by the attending anesthesiologist, surgeon, and pharmacist; and execution of patient care by the anesthesia clinician in the operating room. The authors identified 66 unsafe control actions linked to 342 causal scenarios that could lead to medication errors. Eighty-two (24.0%) scenarios came from perioperative leadership, 103 (30.1%) from management of patient care, and 157 (45.9%) from execution of patient care.

Conclusions: 

In this study, the authors demonstrated the use of systems theoretic process analysis to describe potential causes of errors in the medication use process in the operating room. Causal scenarios were linked to controllers ranging from the frontline providers up to the highest levels of perioperative management. Systems theoretic process analysis is uniquely able to analyze management and leadership impacts on the system, making it useful for guiding quality improvement initiatives. 

WHAT WE ALREADY KNOW ABOUT THIS TOPIC: 

Medication error in the operating room is common. Systems theoretic process analysis is a prospective engineering modeling technique that uses systems theory to identify hazards. 

WHAT THIS ARTICLE TELLS US THAT IS NEW: 

A systems theoretic process analysis identified unsafe control actions linked to causal scenarios that could lead to medication errors. Scenarios came from perioperative leadership, management of patient care, and execution of patient care.

本文由作者自行上传,并且作者对本文图文涉及知识产权负全部责任。如有侵权请及时联系(邮箱:guikequan@hmkx.cn
关键词:
分析,系统论,过程

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