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错误的拔牙部位是否应被归类为永不发生的医疗差错?

Should wrong extraction site be classed as a never event?

机构信息

Barts and the London School of Medicine and Dentistry.

出版信息

Br Dent J. 2018 Aug 24;225(4):291-292. doi: 10.1038/sj.bdj.2018.649. Epub 2018 Aug 17.

DOI:10.1038/sj.bdj.2018.649
PMID:30117499
Abstract

NHS England has set out plans for combatting the rise in never events in the realm of dentistry. This Opinion article investigates the root cause of never events, whether a wrong site surgery should be deemed a never event, and whether the approaches adopted to reduce risk exposure, such as local safety standards for invasive procedures (LocSSIPS), are helping or hindering safe medical care.

摘要

NHS England 已制定计划,以应对牙科领域不断增加的“永不发生”事件。本文探讨了永不发生事件的根本原因,是否应将手术部位错误视为永不发生事件,以及为降低风险而采用的方法(如局部侵袭性手术安全标准 [LocSSIPS])是否有助于或阻碍安全的医疗保健。

相似文献

1
Should wrong extraction site be classed as a never event?错误的拔牙部位是否应被归类为永不发生的医疗差错?
Br Dent J. 2018 Aug 24;225(4):291-292. doi: 10.1038/sj.bdj.2018.649. Epub 2018 Aug 17.
2
Wrong tooth extraction: an examination of 'Never Event' data.错误拔牙:对“严重可避免不良事件”数据的审查。
Br J Oral Maxillofac Surg. 2017 Feb;55(2):187-188. doi: 10.1016/j.bjoms.2016.05.032. Epub 2016 Jun 17.
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Implementation of "local safety standards for invasive procedures (LocSSIPs)" policy: not merely a tick-box exercise in patient safety.实施“侵入性操作地方安全标准(LocSSIPs)”政策:不仅仅是患者安全方面的一项打勾式任务。
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Wrong-site tooth extraction removed from the list of NHS never events - implications for OMFS.《NHS 永远不要发生的事件清单中移除了错误部位拔牙——对口腔颌面外科的影响》。
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Preventing wrong tooth extraction in primary care oral surgery: developing local safety standards for invasive procedures (LocSSIPs).初级保健口腔外科中预防错误拔牙:制定侵袭性操作的当地安全标准(LocSSIPs)。
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Improving patient safety through a clinical audit spiral: prevention of wrong tooth extraction in orthodontics.通过临床审核循环提高患者安全:预防正畸治疗中的误拔牙
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Preventing wrong tooth extraction: experience in development and implementation of an outpatient safety checklist.预防误拔牙齿:门诊安全检查表的制定与实施经验
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Common general surgical never events: analysis of NHS England never event data.常见普通外科的无预警事件:英国国家医疗服务体系无预警事件数据的分析。
Int J Qual Health Care. 2021 Mar 17;33(1). doi: 10.1093/intqhc/mzab045.

本文引用的文献

1
Wrong tooth extraction: an examination of 'Never Event' data.错误拔牙:对“严重可避免不良事件”数据的审查。
Br J Oral Maxillofac Surg. 2017 Feb;55(2):187-188. doi: 10.1016/j.bjoms.2016.05.032. Epub 2016 Jun 17.
2
Tooth loss and oral health-related quality of life: a systematic review and meta-analysis.牙齿缺失与口腔健康相关生活质量:系统评价与荟萃分析。
Health Qual Life Outcomes. 2010 Nov 5;8:126. doi: 10.1186/1477-7525-8-126.
3
Clarifying "never events and introducing "always events".澄清“绝不发生事件”并引入“总是发生事件”。
Patient Saf Surg. 2009 Dec 31;3:26. doi: 10.1186/1754-9493-3-26.
4
The Swiss cheese model of safety incidents: are there holes in the metaphor?安全事件的瑞士奶酪模型:这个比喻有漏洞吗?
BMC Health Serv Res. 2005 Nov 9;5:71. doi: 10.1186/1472-6963-5-71.