Weingessel Birgit, Haas Michaela, Vécsei Christina, Vécsei-Marlovits Pia Veronika
Department of Ophthalmology, Hietzing Hospital, Vienna, Austria.
Karl Landsteiner Institute for Process Optimization and Quality Management in Cataract Surgery, Vienna, Austria.
Acta Ophthalmol. 2017 Mar;95(2):e89-e94. doi: 10.1111/aos.13155. Epub 2016 Jul 16.
Clinical risk management aims to identify, analyse and avoid errors and risks systematically to improve patient's safety. Preoperative checklists to prevent mistakes have gained importance in the last few years. A so-called team timeout checklist was introduced in October 2011 at the Department of Ophthalmology, Hietzing Hospital, Vienna. The purpose of the study is to evaluate the benefits and demonstrate the value of team timeout.
After the team timeout had been in use for 6 months, all near misses that occurred over a period of 34 months were assigned to the following groups: wrong side, wrong lens, wrong patient and miscellaneous.
Eighteen thousand and eighty-one surgeries were performed in the specified period; 53 cases of 'wrong side' and 52 cases of 'wrong intraocular lens' were noted. Ninety-six near misses concerned the patients' data and 38 concerned documentation. A reduction of near misses was noted after an adaptation phase of 3 months.
Team timeout proved valuable, as it improved the patients' safety with minimum effort. Errors may occur despite several preoperative controls and can be detected by performing team timeout.
临床风险管理旨在系统地识别、分析并避免错误和风险，以提高患者安全。在过去几年中，用于预防错误的术前检查表变得越发重要。2011年10月，维也纳希茨inger医院眼科引入了一种所谓的团队暂停检查表。本研究的目的是评估其益处并证明团队暂停的价值。
在团队暂停检查表使用6个月后，将34个月期间发生的所有险些发生的错误分为以下几组：错误的手术部位、错误的人工晶状体、错误的患者以及其他。
在规定期间共进行了18081台手术；记录到53例“错误的手术部位”和52例“错误的人工晶状体”。96起险些发生的错误与患者数据有关，38起与文件记录有关。经过3个月的适应期后，险些发生的错误有所减少。
团队暂停被证明是有价值的，因为它以最小的努力提高了患者安全。尽管有多项术前检查，仍可能发生错误，而通过团队暂停可以发现这些错误。
