Soncrant Christina M, Warner Lisa J, Neily Julia, Paull Douglas E, Mazzia Lisa, Mills Peter D, Gunnar William, Hemphill Robin R
AORN J. 2018 Oct;108(4):386-397. doi: 10.1002/aorn.12372.
This quality improvement project describes 22 OR patient falls reported in the Veterans Health Administration between January 2010 and February 2016. Most (n = 15; 68%) involved patient falls from the OR bed. Other patient falls (n = 6; 27%) occurred when the patient was transferred to or from the OR bed, and one fall (5%) occurred at another time. Root causes of the falls included tilting of the OR bed, issues with safety restraints, malfunctioning OR bed or gurney locks, inadequate patient sedation, and poor communication among team members. One fall (5%) resulted in a major injury, four falls (18%) resulted in minor injuries, six falls resulted in no injury, and 11 falls (50%) had no reported outcome. Falls in the OR, although rare, can be injurious. We drafted recommendations based on the root causes that include specific guidance on communication, teamwork, best practices, restraints and equipment, and training.
这项质量改进项目描述了2010年1月至2016年2月期间退伍军人健康管理局报告的22起手术室患者跌倒事件。大多数（n = 15；68%）涉及患者从手术床上跌落。其他患者跌倒事件（n = 6；27%）发生在患者从手术床上转移或转移至手术床时，还有1起跌倒事件（5%）发生在其他时间。跌倒的根本原因包括手术床倾斜、安全约束问题、手术床或轮床锁故障、患者镇静不足以及团队成员之间沟通不畅。1起跌倒事件（5%）导致重伤，4起跌倒事件（18%）导致轻伤，6起跌倒事件未造成伤害，11起跌倒事件（50%）未报告结果。手术室中的跌倒虽然罕见，但可能会造成伤害。我们根据根本原因起草了建议，包括关于沟通、团队合作、最佳实践、约束和设备以及培训的具体指导。
