脊柱手术中的事件与事故报告分析及风险管理

Analysis of Incident and Accident Reports and Risk Management in Spine Surgery.

作者信息

Kobayashi Kazuyoshi, Imagama Shiro, Ando Kei, Hida Tetsuro, Ito Kenyu, Tsushima Mikito, Ishikawa Yoshimoto, Matsumoto Akiyuki, Morozumi Masayoshi, Nishida Yoshihiro, Nagao Yoshimasa, Ishiguro Naoki

机构信息

Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Aichi, Nagoya, Japan.

Department of Quality and Patient Safety, Nagoya University Hospital, Aichi, Nagoya, Japan.

出版信息

Spine (Phila Pa 1976). 2017 Aug 1;42(15):1184-1188. doi: 10.1097/BRS.0000000000002072.

DOI:10.1097/BRS.0000000000002072

PMID:28098743

Abstract

STUDY DESIGN

A review of accident and incident reports.

OBJECTIVE

To analyze prevalence, characteristics, and details of perioperative incidents and accidents in patients receiving spine surgery.

SUMMARY OF BACKGROUND DATA

In our institution, a clinical error that potentially results in an adverse event is usually submitted as an incident or accident report through a web database, to ensure anonymous and blame-free reporting. All reports are analyzed by a medical safety management group. These reports contain valuable data for management of medical safety, but there have been no studies evaluating such data for spine surgery.

METHODS

A total of 320 incidents and accidents that occurred perioperatively in 172 of 415 spine surgeries were included in the study. Incidents were defined as events that were "problematic, but with no damage to the patient," and accidents as events "with damage to the patient." The details of these events were analyzed.

RESULTS

There were 278 incidents in 137 surgeries and 42 accidents in 35 surgeries, giving prevalence of 33% (137/415) and 8% (35/415), respectively. The proportion of accidents among all events was significantly higher for doctors than non-doctors [68.0% (17/25) vs. 8.5% (25/295), P < 0.01] and in the operating room compared with outside the operating room [40.5% (15/37) vs. 9.5% (27/283), P < 0.01]. There was no significant difference in years of experience among personnel involved in all events. The major types of events were medication-related, line and tube problems, and falls and slips. Accidents also occurred because of a long-term prone position, with complications such as laryngeal edema, ulnar nerve palsy, and tooth damage.

CONCLUSION

Surgery and procedures in the operating room always have a risk of complications. Therefore, a particular effort is needed to establish safe management of this environment and to provide advice on risk to the doctor and medical care team.

LEVEL OF EVIDENCE

摘要

研究设计

对事故和事件报告进行回顾。

目的

分析接受脊柱手术患者围手术期事件和事故的发生率、特征及细节。

背景数据总结

在我们机构，可能导致不良事件的临床错误通常通过网络数据库提交为事件或事故报告，以确保匿名且无指责报告。所有报告均由医疗安全管理小组进行分析。这些报告包含医疗安全管理的宝贵数据，但尚无研究评估脊柱手术的此类数据。

方法

本研究纳入了415例脊柱手术中172例围手术期发生的320起事件和事故。事件定义为“有问题但未对患者造成损害”的事件，事故定义为“对患者造成损害”的事件。对这些事件的细节进行了分析。

结果

137例手术中有278起事件，35例手术中有42起事故，发生率分别为33%（137/415）和8%（35/415）。医生发生的事故在所有事件中的比例显著高于非医生[68.0%（17/25）对8.5%（25/295），P<0.01]，且在手术室发生的事故比例高于手术室以外[40.5%（15/37）对9.5%（27/283），P<0.01]。所有事件相关人员的工作年限无显著差异。主要事件类型为药物相关、管路问题以及跌倒和滑倒。事故还因长期俯卧位发生，伴有喉水肿、尺神经麻痹和牙齿损伤等并发症。