1例气管切开患者居家环境下留置鼻胃管误入气管的启示  

Inspiration of 1 case of tracheotomy patient with indwelling nasogastric tube mistakenly into trachea in home environment

作　　者：卢来新 刘红华 王玉连[3] LU Laixin;LIU Honghua;WANG Yulian(Department of General Medicine,Huangzhou District Chibi Community Health Service Center of Huanggang,Huanggang,Hubei 438000,China;Department of Geriatrics,Huangpi District Traditional Chinese Medicine Hospital,Wuhan,Hubei 430300,China;Department of General Medicine,Huanggang Hospital of Traditional Chinese Medicine,Huanggang,Hubei 438000,China)

机构地区：[1]黄冈市黄州区赤壁社区卫生服务中心全科医学科,湖北黄冈438000 [2]黄陂区中医医院老年医学科,湖北武汉430300 [3]黄冈市中医医院全科医学科,湖北黄冈438000

出　　处：《医药前沿》2025年第11期79-81,共3页Journal of Frontiers of Medicine

摘　　要：气管切开是临床常见的一种治疗手段,而不少气管切开患者,同时还留置鼻胃管。鼻胃管留置过程中可能误入气道,患者通常表现为呛咳、呼吸困难、嘴唇发绀和痛苦面容等,操作人员也会通过患者是否出现上述表现来判断鼻胃管是否误入气管。本文报道1例气管切开患者在居家环境下留置鼻胃管时,鼻胃管误入气管,然而,患者并未表现出刺激性呛咳、呼吸困难和发绀等常见异常表现。本文通过根本原因分析法从系统因素和人为因素2个层面深入剖析该病例操作失误的原因,总结经验教训,以期为类似场景的风险防范和质量改进提供重要启示。Tracheotomy is a common clinical treatment,and many patients with tracheotomy,but also indwelling nasogastric tube.The nasogastric tube may be mistakenly inserted into the airway during the indwelling process.Patients usually have cough,dyspnea,cyanosis of lips,and painful faces.The operator will also determine whether the nasogastric tube is mistakenly inserted into the trachea by whether the patient has the above manifestations.This article reported 1 case of tracheotomy patient with nasogastric tube misplaced into the trachea when indwelling nasogastric tube in the home environment.However,the patient did not show common abnormalities such as irritating cough,dyspnea and cyanosis.In this paper,the root cause analysis method is used to deeply analyze the causes of the operation error of the case from the two levels of system factors and human factors,and summarize the experience and lessons,so as to provide important enlightenment for risk prevention and quality improvement of similar scenarios.

关 键 词：居家诊疗 气管切开 鼻胃管 根本原因分析法 系统因素 人为因素 

分 类 号：R562[医药卫生—呼吸系统]