Wolff Kristina B, Soncrant Christina, Mills Peter D, Hemphill Robin R
1 VA National Center for Patient Safety Field Office (NCPS), White River Junction, VT.
2 The Geisel School of Medicine at Dartmouth College, Hanover, NH.
Am J Med Qual. 2017 Jul/Aug;32(4):445-452. doi: 10.1177/1062860616658343. Epub 2016 Jul 11.
The objective was to analyze reported flash burns experienced by patients on home oxygen therapy (HOT) in the Veterans Health Administration (VHA) using a qualitative, retrospective review of VHA root cause analysis reports between January 2009 and November 2015. Of 123 cases of reported adverse events related to flash burns, 100 cases (81%) resulted in injury, and 23 (19%) resulted in death. Although 89% of veterans claimed to have quit smoking (n = 109), 92% (n = 113) of burns occurred as a result of smoking. The most common root cause was risk identification issues. Recommended actions were standardized risk assessment policies, patient education, and the adoption of fire stop valves. Patients with a history of smoking who are on HOT should be considered for fire stop valves and offered consistent counseling and follow-up using a combination of harm reduction and shared decision-making techniques. Standardization of risk identification and documentation is recommended.
目的是通过对2009年1月至2015年11月期间退伍军人健康管理局（VHA）的根本原因分析报告进行定性回顾性分析，来分析接受家庭氧疗（HOT）的患者报告的闪燃烧伤情况。在123例报告的与闪燃烧伤相关的不良事件中，100例（81%）导致受伤，23例（19%）导致死亡。尽管89%的退伍军人声称已戒烟（n = 109），但92%（n = 113）的烧伤是由吸烟引起的。最常见的根本原因是风险识别问题。建议采取的措施包括标准化风险评估政策、患者教育以及采用防火阀。对于有吸烟史且接受家庭氧疗的患者，应考虑安装防火阀，并使用减少危害和共同决策技术相结合的方式提供持续的咨询和随访。建议对风险识别和记录进行标准化。
