53例麻醉相关不良事件分析与改进对策  

Analysis on 53 Cases of Anaesthesia Related Adverse Events and Improvement Strategies

作　　者：焦峰[1] 王欣[1] 刘春玲[1] 李小莹[1] 冯雪辛[1] Jiao Feng;Wang Xin;Liu Chunling;Li Xiaoying;Feng Xuexin(Xuanwu Hospital of Capital Medical University,Beijing 100053,China)

机构地区：[1]首都医科大学宣武医院,北京市100053

出　　处：《中国病案》2018年第11期12-14,共3页Chinese Medical Record

基　　金：首都医科大学校长基金项目(16GLY18)

摘　　要：目的分析麻醉相关不良事件发生的原因,提出改进对策,保证手术患者安全。方法对某院2017年1月-2018年6月通过医院医疗安全不良事件系统上报的麻醉相关不良事件,进行回顾性麻醉相关不良事件的分级、发生时间及发生原因等进行统计分析。结果麻醉相关不良事件的主要原因是未严格执行操作规范或规章制度(32.08%)、经验储备不足(22.64%)和技术操作失误(18.87%)等,占上报不良事件总数的73.58%。Ⅱ级不良事件占5.66%,Ⅲ级不良事件占71.70%,Ⅳ级不良事件占22.64%。结论鼓励无责上报,集体分析与反馈,重复事件重点分析,加强培训,做好器械设备维护,能够有效的防止麻醉不良事件的发生,有利于提高患者麻醉质量和医疗安全。Objectives The causes of anaesthesia related adverse events were analyzed, and the improvement measures were put forward to ensure the safety of surgical patients. Methods The adverse events related to anesthesia reported in our hospital were analyzed retrospectively. A retrospective analysis of adverse events related to anesthesia. Results The major causes of anaesthesia related adverse events were the failure to strictly implement operation specifications or regulations（32.08%）, insufficient experience reserve（22.64%） and technical operation error（18.87%）, which accounted for 73.58% of the total reported adverse events. Conclusions It could effectively prevent the occurrence of adverse anesthesia events and improve the anesthetic quality and medical safety by encouraging reports without responsibility, collective analysis and feedback, key analysis of repeated events, strengthening training and maintenance of equipment and facilities.

关 键 词：麻醉 不良事件 安全管理 

分 类 号：R197.323[医药卫生—卫生事业管理]