非计划再次手术原因  

Cause Analysis of Unplanned Reoperation

作　　者：廖祺 陈洪 孙启荻 LIAO Qi;CHEN Hong;SUN Qidi(Quality Management Division,Army Medical Center of PLA,Chongqing 400042;Military Medical Training Center,Army Medical Center of PLA,Chongqing 400042)

机构地区：[1]陆军特色医学中心质量管理科,重庆400042 [2]陆军特色医学中心卫勤训练中心,重庆400042

出　　处：《解放军医院管理杂志》2020年第9期818-820,共3页Hospital Administration Journal of Chinese People's Liberation Army

摘　　要：目的分析2019年非计划再次手术的发生率及发生原因,探讨非计划再次手术的管理措施。方法回顾性分析某医院2019年非计划再次手术病例,汇总上报情况,计算不同科室的发生率,探究发生原因。结果非计划再次手术110例,发生率0.21%;主要发生在神经外科、胸外科、脊柱外科、乳甲外科、心脏外科;术后出血、吻合口瘘、术后感染、手术损伤邻近器官、脑水肿为主要原因;非计划再次手术漏报20例、迟报7例、未分析讨论23例,漏报率15.7%、迟报率6.4%、未分析讨论率20.9%。结论加强围术期质量管理,探索现代化的监管方法,降低非计划再次手术的发生率,全面提高医疗质量与安全。Objective To analyze data and root cause of unplanned reoperations in 2019 retrospectively and discuss corresponding management measurements.Methods Analyze unplanned reoperations in 2019 of a hospital retrospectively,summarize reports and calculate occurrence rate in different departments and find out the causes.Result There were 110 unplanned reoperations in total(occurrence rate 0.21%),mainly in neurosurgery,thoracic surgery,spinal surgery,breast and thyroid surgery,cardiac surgery;the main reasons related were postoperative hemorrhage,anastomotic fistula,postoperative infection,surgical injury of adjacent organs and cerebral edema.There were 20 underreports(15.7%),7 late reports(6.4%)and 23 non-discussed reports(20.9%).Conclusion It is necessary to strengthen perioperative quality management and explore modern supervision methods to reduce unplanned reoperation incidents and improve medical quality and safety comprehensively.

关 键 词：非计划再次手术 医疗质量 原因分析 

分 类 号：R197.32[医药卫生—卫生事业管理]