Esmail Rosmin, Cummings Cheryl, Dersch Deonne, Duchscherer Greg, Glowa Judy, Liggett Gail, Hulme Terrance
Calgary Health Region, Calgary, Alberta, Canada.
Healthc Q. 2005;8 Spec No:73-80. doi: 10.12927/hcq.2005.17668.
During the spring of 2004, in the Calgary Health Region (CHR) two critical incidents occurred involving patients receiving continuous renal replacement therapy (CRRT) in the intensive care unit (ICU). The outcome of these events resulted in the sudden death of both patients. The Department of Critical Care Medicine's Patient Safety and Adverse Events Team (PSAT), utilized the Healthcare Failure Mode and Effect Analysis (HFMEA) tool to review the process and conditions surrounding the ordering and administration of potassium chloride (KCI) and potassium phosphate (KPO4) in our ICUs. The HFMEA tool and the multidisciplinary team structure provided a solid framework for systematic analysis and prioritization of areas for improvement regarding the use of intravenous, high-concentration KCL and KPO4 in the ICU.
2004年春季，卡尔加里健康区域（CHR）的重症监护病房（ICU）发生了两起涉及接受持续肾脏替代疗法（CRRT）患者的严重事件。这些事件的结果导致两名患者突然死亡。重症医学科的患者安全与不良事件团队（PSAT）利用医疗失效模式与效应分析（HFMEA）工具，审查了我们ICU中氯化钾（KCI）和磷酸钾（KPO4）的医嘱开具及给药过程和情况。HFMEA工具和多学科团队结构为系统分析以及对ICU中静脉注射高浓度KCL和KPO4使用方面的改进领域进行优先级排序提供了坚实的框架。
