Medical Imaging Center, Department of Radiology, Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, the Netherlands.
Nucl Med Commun. 2020 Nov;41(11):1111-1116. doi: 10.1097/MNM.0000000000001262.
To determine the types of patient safety incidents and associated harm in nuclear medicine practice.
This study included 147 patient safety incidents related to nuclear medicine practice and submitted to the incident reporting system of a tertiary care nuclear medicine department between 2014 and 2019.
The top-three incident types according to the International Classification for Patient Safety (ICPS) were medication/IV fluids (36/147, 24.5%), clinical administration (28/147, 19.0%), and clinical process/procedure (27/147, 18.4%), altogether comprising 61.9% of incidents. Within the medication/IV fluids domain, half of incident subtypes were attributable to supply/ordering, omitted medicine or dose, and wrong dose/strength of frequency. Within the clinical administration domain, appointment and wrong patient represented the majority of incident subtypes. Within the clinical process/procedure domain, the majority of incident subtypes fell in the categories: specimens/results and incomplete/inadequate. There was no patient harm in 145 (98.6%) of cases, mild patient harm in 1 (0.7%) case, and in 1 (0.7%) case, it remained unclear if there was patient harm. In 4 (2.7%) cases, a Prevention Recovery Information System for Monitoring and Analysis evaluation was performed because of the high risk of reoccurrence and patient harm.
The majority of patient safety incidents in nuclear medicine occur in three main ICPS categories (medication/IV fluids, clinical administration, and clinical process/procedure, in order of decreasing frequency). These can be considered as key strategic areas for incident prevention and patient safety improvement. Nevertheless, the rate of actual patient harm was very low in our series.
确定核医学实践中患者安全事件的类型及其相关伤害。
本研究纳入了 2014 年至 2019 年期间向一家三级核医学部门的事件报告系统提交的 147 例与核医学实践相关的患者安全事件。
根据国际患者安全分类（ICPS），发生率最高的三种事件类型为药物/静脉输液（36/147，24.5%）、临床给药（28/147，19.0%）和临床过程/程序（27/147，18.4%），共占事件总数的 61.9%。在药物/静脉输液领域，一半的亚型归因于供应/医嘱、漏用药或剂量、以及用药错误或剂量/频次错误。在临床给药领域，预约和错误的患者占多数。在临床过程/程序领域，大多数亚型属于标本/结果和不完整/不充分。145 例（98.6%）患者无伤害，1 例（0.7%）为轻度伤害，1 例（0.7%）伤害情况尚不清楚。由于再发风险和患者伤害高，4 例（2.7%）患者进行了预防恢复信息系统监测和分析评估。
核医学中大多数患者安全事件发生在三个主要的 ICPS 类别（按频率递减顺序分别为药物/静脉输液、临床给药和临床过程/程序）中。这些类别可被视为事件预防和患者安全改进的关键战略领域。然而，在我们的研究系列中，实际发生患者伤害的比例非常低。
