Ten Haken Ingrid, Ben Allouch Somaya, van Harten Wim H
Research Group Technology, Health & Care, Saxion University of Applied Sciences, Enschede, The Netherlands
Research Group Digital Life, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands.
BMJ Qual Saf. 2020 Jun 16;30(5):380-7. doi: 10.1136/bmjqs-2019-010510.
Advanced medical technologies (AMTs), such as respiratory support or suction devices, are increasingly used in home settings and incidents may well result in patient harm. Information about risks and incidents can contribute to improved patient safety, provided that those are reported and analysed systematically.
To identify the frequency of incidents when using AMTs in home settings, the effects on patient outcomes and the actions taken by nurses following identification of incidents.
A cross-sectional study of 209 home care nurses in the Netherlands working with infusion therapy, parenteral nutrition or morphine pumps, combining data from a questionnaire and registration forms covering more than 13 000 patient contacts. Descriptive statistics were used.
We identified 140 incidents (57 adverse events; 83 near misses). The frequencies in relation to the number of patient contacts were 2.7% for infusion therapy, 1.3% for parenteral nutrition and 2.6% for morphine pumps. The main causes were identified as related to the product (43.6%), the organisation of care (27.9%), the nurse as a user (15.7%) and the environment (12.9%). 40% of all adverse events resulted in mild to severe harm to the patient. Incidents had been discussed in the team (70.7%), with the patient/informal caregiver(s) (50%), or other actions had been taken (40.5%). 15.5% of incidents had been formally reported according to the organisation's protocol.
Most incidents are attributed to product failures. Although such events predominantly cause no harm, a significant proportion of patients do suffer some degree of harm. There is considerable underreporting of incidents with AMTs in home care. This study has identified a discrepancy in quality circles: learning takes place at the team level rather than at the organisational level.
先进医疗技术（如呼吸支持或吸引装置）在家庭环境中的使用日益增多，且这些装置引发的事件很可能导致患者受到伤害。若能对风险和事件进行系统报告与分析，相关信息将有助于提高患者安全。
确定家庭环境中使用先进医疗技术时事件的发生频率、对患者结局的影响以及护士在识别事件后采取的行动。
对荷兰209名从事输液治疗、肠外营养或吗啡泵护理工作的家庭护理护士进行横断面研究，结合来自问卷和登记表的数据，涵盖超过13000次患者接触。采用描述性统计方法。
我们识别出140起事件（57起不良事件；83起险些失误）。与患者接触次数相关的发生率分别为：输液治疗2.7%，肠外营养1.3%，吗啡泵2.6%。主要原因被确定为与产品（43.6%）、护理组织（27.9%）、护士作为使用者（15.7%）和环境（12.9%）有关。所有不良事件中有40%导致患者受到轻度至重度伤害。事件已在团队中讨论（70.7%），与患者/非正式护理人员讨论过（50%），或采取了其他行动（40.5%）。15.5%的事件已根据机构规程进行正式报告。
大多数事件归因于产品故障。尽管此类事件大多未造成伤害，但仍有相当比例的患者遭受了一定程度的伤害。家庭护理中先进医疗技术事件的报告严重不足。本研究发现了质量改进小组中的一个差异：学习发生在团队层面而非组织层面。
