Şalvız Emine Aysu, Edipoğlu Saadet İpek, Sungur Mukadder Orhan, Altun Demet, Büget Mehmet İlke, Seyhan Tülay Özkan
Department of Anaesthesiology, İstanbul University School of Medicine, İstanbul, Turkey.
Clinic of Anaesthesiology, Süleymaniye Training and Research Hospital, İstanbul, Turkey.
Turk J Anaesthesiol Reanim. 2016 Apr;44(2):59-70. doi: 10.5152/TJAR.2016.75133. Epub 2016 Apr 1.
Critical incident reporting systems (CIRS) and morbidity-mortality meetings (MMMs) offer the advantages of identifying potential risks in patients. They are key tools in improving patient safety in healthcare systems by modifying the attitudes of clinicians, nurses and staff (human error) and also the system (human and/or technical error) according to the analysis and the results of incidents.
One anaesthetist assigned to an administrative and/or teaching position from all university hospitals (UHs) and training and research hospitals (TRHs) of Turkey (n=114) was contacted. In this survey study, we analysed the facilities of anaesthetists in Turkish UHs and TRHs with respect to CIRS and MMMs and also the anaesthetists' knowledge, experience and attitudes regarding CIs.
Anaesthetists from 81 of 114 teaching hospitals replied to our survey. Although 96.3% of anaesthetists indicated CI reporting as a necessity, only 37% of departments/hospitals were reported to have CIRS. True definition of CI as "an unexpected /accidental event" was achieved by 23.3% of anaesthetists with CIRS. MMMs were reported in 60.5% of hospitals. Nevertheless, 96% of anaesthetists believe that CIRS and MMMs decrease the incidence of CI occurring. CI occurrence was attributed to human error as 4 [1-5]/10 and 3 [1-5]/10 in UHs and TRHs, respectively (p=0.005). In both hospital types, technical errors were evaluated as 3 [1-5]/10 (p=0.498).
This first study regarding CIRS in the Turkish anaesthesia departments/hospitals highlights the lack of CI knowledge and CIRS awareness and use in anaesthesia departments/teaching hospitals in Turkey despite a safety reporting system set up by the Turkish Ministry of Health.
危急事件报告系统(CIRS)和发病率 - 死亡率会议(MMMs)具有识别患者潜在风险的优势。它们是通过根据事件分析和结果改变临床医生、护士及工作人员的态度(人为错误)以及系统(人为和/或技术错误)来提高医疗系统中患者安全的关键工具。
联系了土耳其所有大学医院(UHs)以及培训和研究医院(TRHs)中被分配到行政和/或教学岗位的一名麻醉医生(n = 114)。在这项调查研究中,我们分析了土耳其UHs和TRHs中麻醉医生在CIRS和MMMs方面的设施情况,以及麻醉医生对危急事件的知识、经验和态度。
114家教学医院中的81家医院的麻醉医生回复了我们的调查。尽管96.3%的麻醉医生表示有必要报告危急事件,但只有37%的科室/医院设有CIRS。23.3%设有CIRS的麻醉医生能正确将危急事件定义为“意外/偶然事件”。60.5%的医院报告有MMMs。然而,96%的麻醉医生认为CIRS和MMMs能降低危急事件的发生率。在大学医院和培训与研究医院中,危急事件的发生分别归因于人为错误的比例为4[1 - 5]/10和3[1 - 5]/10(p = 0.005)。在这两种类型的医院中,技术错误的评分为3[1 - 5]/10(p = 0.498)。
这项关于土耳其麻醉科室/医院CIRS的首次研究凸显出,尽管土耳其卫生部设立了安全报告系统,但土耳其麻醉科室/教学医院在危急事件知识、CIRS意识及使用方面仍存在不足。