Minekus Joanne P J, Rozing Piet M, Nelissen Rob, Dankelman Jenny
Delft University of Technology, Faculty of Design, Engineering and Production, The Netherlands.
Clin Orthop Relat Res. 2005 Aug(437):121-7. doi: 10.1097/01.blo.0000166900.84323.14.
The aim of our study was to identify errors and error pathways during joint replacements and to propose improvements. A time-action and error analysis method was adapted for use during surgery. The error analysis consisted of identifying all possible errors, determining error paths presented in an error chart, quantifying errors, and determining the impact of errors. This method was used to evaluate joint replacements. We evaluated five knee and 11 elbow replacements done by two experienced surgeons. The main error for elbow replacements was caused by inadequate instruments. The main error for knee replacements was caused by inexperienced nurses being unfamiliar with guiding instruments. The time-action analysis showed a large variation in procedure duration. The main surgical limitations for both procedures were waiting caused by the cementing process and waiting caused by inexperienced scrub nurses. Our study identified errors and surgical limitations during joint replacements by using time-action and error analysis. Placement of both prostheses will benefit from new fixation techniques, a more experienced nursing staff, and more organized instrument tables.
我们研究的目的是识别关节置换手术过程中的错误及错误路径，并提出改进建议。一种时间动作与错误分析方法被应用于手术过程中。错误分析包括识别所有可能的错误、确定错误图表中呈现的错误路径、量化错误以及确定错误的影响。该方法被用于评估关节置换手术。我们评估了两位经验丰富的外科医生进行的5例膝关节置换手术和11例肘关节置换手术。肘关节置换手术的主要错误是由器械不足导致的。膝关节置换手术的主要错误是由缺乏经验的护士不熟悉引导器械导致的。时间动作分析显示手术持续时间差异很大。这两种手术的主要手术限制都是由骨水泥固定过程导致的等待以及缺乏经验的洗手护士导致的等待。我们的研究通过使用时间动作与错误分析识别了关节置换手术中的错误和手术限制。两种假体的植入将受益于新的固定技术、经验更丰富的护理人员以及更有序的器械台。
