Wubben I, van Manen J G, van den Akker B J, Vaartjes S R, van Harten W H
Department of Health Technology and Services Research, University of Twente, PO Box 217, 7500 AE Enschede, The Netherlands.
Qual Saf Health Care. 2010 Dec;19(6):e64. doi: 10.1136/qshc.2009.037515. Epub 2010 Jun 16.
Equipment-related incidents in the operating room (OR) can affect quality of care. In this study, the authors determined the occurrence and effects on the care process in a large teaching hospital.
During a 4-week period, OR nurses reported equipment-related incidents during surgery procedures in both locations of the hospital. The incidents were reported using a separate form for each incident. A structured analysis (PRISMA) was used to analyse incidents that resulted in serious delays (>15 min).
Forms were returned for 911 out of 1580 surgeries (57.7%). In total, 148 incidents were registered, relating to a total of 29 h and 45 min of extra work. In addition, 12 h and 9 min of operational delay was registered. Most incidents involved instruments (46%) or medical devices (28%). 68% occurred during surgery and 32% during the preparation phase. No direct physical harm was reported, although indirect harm, like longer anaesthesia, did occur and can be defined as an adverse event. 10% of the incidents led to a delay of over 15 min. For these incidents, 'management decisions' (eg, inventory capacity, planning procedure) was the most encountered root cause. Only six out of the 148 incidents found corresponded with the blame-free reporting database.
Equipment-related incidents occurred frequently in the involved hospital sites (up to 15.9%) and resulted in some extra work and additional minutes of delay per event. Management decisions have considerable influence on the occurrence of equipment-related incidents. There was serious under-reporting of incidents.
手术室中的设备相关事件会影响护理质量。在本研究中，作者确定了一家大型教学医院中此类事件的发生率及其对护理过程的影响。
在为期4周的时间里，手术室护士报告了医院两个院区手术过程中发生的设备相关事件。每个事件都使用单独的表格进行报告。采用结构化分析（PRISMA）来分析导致严重延误（>15分钟）的事件。
1580例手术中有911例（57.7%）返回了表格。总共记录了148起事件，共计额外工作29小时45分钟。此外，还记录了12小时9分钟的手术延误。大多数事件涉及器械（46%）或医疗设备（28%）。68%的事件发生在手术期间，32%发生在准备阶段。虽然没有报告直接的身体伤害，但确实发生了如麻醉时间延长等间接伤害，可将其定义为不良事件。10%的事件导致延误超过15分钟。对于这些事件，“管理决策”（如库存容量、计划程序）是最常见的根本原因。在148起发现的事件中，只有6起与无责报告数据库相符。
在所涉医院院区，设备相关事件频繁发生（发生率高达15.9%），且每次事件都会导致一些额外工作和更多的延误时间。管理决策对设备相关事件的发生有相当大的影响。事件报告严重不足。
