Göransson Katarina, Lundberg Johan, Ljungqvist Olle, Ohlsson Elisabet, Sandblom Gabriel
Department of Intensive Care and Perioperative Medicine, Skåne University Hospital, Lund, Sweden.
Dept of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
Patient Saf Surg. 2016 Jan 13;10:2. doi: 10.1186/s13037-015-0089-y. eCollection 2016.
Many adverse events occur due to poor communication between surgical and anesthesia unit personnel. The aim of this study was to identify strategies to reduce risks unveiled by a national survey on patient safety.
During 2011-2015, specially trained survey teams visited the surgery departments at Swedish hospitals and documented routines concerning safety in abdominal surgery. The reports from the first seventeen visits were reviewed by an independent group in order to extract findings related to routines in communication between anesthesia and surgical unit personnel.
In general, routines regarding preoperative risk assessment were safe and well- coordinated. On the other hand, routines regarding medication prior to surgery, reporting between the different units, and systems for reporting and providing feedback on adverse events were poor or missing. Strategies with highest priority include: 1. a uniform national health declaration form; 2. consistent use of admission notes; 3. systems for documenting all important medical information, that is accessible to everyone; 4. a multidisciplinary forum for the evaluation of high-risk patients; 5. weekly and daily scheduling of surgical programs; 6. application of the WHO check list; 7. open dialog during surgery; 8. reporting based on SBAR; 9. oral and written reports from the surgeon to the postoperative unit; and 10. combined mortality and morbidity conferences.
One repeatedly occurring hazard endangering patient safety was related to communication between surgical and anesthesia unit personnel. Strategies to reduce this hazard are suggested, but further research is required to test their effectiveness.
由于外科和麻醉科人员之间沟通不畅，许多不良事件时有发生。本研究旨在确定可降低一项全国患者安全调查所揭示风险的策略。
在2011年至2015年期间，经过专门培训的调查小组走访了瑞典医院的外科科室，并记录了腹部手术安全方面的常规做法。前十七次走访的报告由一个独立小组进行审查，以便提取与麻醉科和外科科室人员沟通常规做法相关的调查结果。
总体而言，术前风险评估的常规做法安全且协调良好。另一方面，术前用药、不同科室之间的报告以及不良事件报告和反馈系统方面的常规做法较差或缺失。最优先的策略包括：1. 统一的全国健康申报表格；2. 一致使用入院记录；3. 记录所有重要医疗信息且人人均可获取的系统；4. 评估高危患者的多学科论坛；5. 手术计划的每周和每日安排；6. 应用世界卫生组织检查表；7. 手术期间的开放对话；8. 基于SBAR的报告；9. 外科医生向术后科室的口头和书面报告；以及10. 死亡率和发病率联合会议。
一个反复出现的危及患者安全的危险因素与外科和麻醉科人员之间的沟通有关。提出了降低这一危险因素的策略，但需要进一步研究以检验其有效性。
