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沙特阿拉伯利雅得一家三级护理教学医院对未遂事件的回顾性分析。

A retrospective analysis of near-miss incidents at a tertiary care teaching hospital in Riyadh, KSA.

作者信息

Memon Sajjan Iqbal

机构信息

Department of Health Administration, King Saud University Riyadh KSA.

出版信息

J Taibah Univ Med Sci. 2022 Jan 22;17(2):235-240. doi: 10.1016/j.jtumed.2021.11.014. eCollection 2022 Apr.

DOI:10.1016/j.jtumed.2021.11.014
PMID:35592803
原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC9073884/
Abstract

OBJECTIVE

This study seeks to establish an error-free reporting system that enhances patient safety and organisational culture. It investigates the prevalence of near-miss incident reporting systems by healthcare professionals in the General Surgery Department.

METHODS

This retrospective observational study was conducted at a tertiary care teaching hospital in Riyadh, KSA. A sample of 253 medical records, ranging from January 2018 to December 2020, belonging to secondary patients was obtained using the near-miss Datix reporting and occurrence variance reporting system. The demographic variable data of registered patients were based on their age group (18-80 years), length of stay, date of admission, medication prescribed for more than four days, and whether they underwent surgical interventions. The cases were documented after the occurrence of a near-miss incident using a convenience sampling technique.

RESULTS

In terms of prevalence in the near-miss main categories, medical errors were 248 (98.2%), workplace violations were two (0.80%), and others was one (0.40%). The number of incidence in the subcategories were: prescribing, 227 (89.7%); dispensing, 16 (6.30%) wrong dose/strength, 118 (46.6%), male, 123 (48.6%), and female, 130 (51.4%). The mean age and S.D. of patients was 1.94 ± 0.88 years and the demographic nationality as 1.16 ± 0.37. The one-sample t-test value for the main categories was -235 (-value < 0.001).

CONCLUSION

Near-misses are recognised as essential targets for continuous quality improvement tools to mitigate preoperative incidents in hospitals. These findings can benefit the advancement of techniques for improving guidelines related to compliance and effective communication to improve the preoperative safety of patients.

摘要

目的

本研究旨在建立一个无差错报告系统,以提高患者安全和组织文化。它调查了普通外科医护人员对医疗差错未遂事件报告系统的使用情况。

方法

这项回顾性观察研究在沙特阿拉伯利雅得的一家三级护理教学医院进行。使用医疗差错未遂事件的Datix报告和事件差异报告系统,获取了2018年1月至2020年12月期间属于二级患者的253份病历样本。登记患者的人口统计学变量数据基于他们的年龄组(18 - 80岁)、住院时间、入院日期、用药超过四天的情况以及是否接受了手术干预。使用便利抽样技术,在医疗差错未遂事件发生后记录病例。

结果

在医疗差错未遂主要类别方面,医疗差错有248例(98.2%),工作场所违规有2例(0.80%),其他有1例(0.40%)。子类别中的发生率为:处方,227例(89.7%);配药,16例(6.30%);错误剂量/强度,118例(46.6%);男性,123例(48.6%),女性,130例(51.4%)。患者平均年龄和标准差为1.94 ± 0.88岁,人口统计学国籍为1.16 ± 0.37。主要类别的单样本t检验值为 -235(p值 < 0.001)。

结论

医疗差错未遂被认为是持续质量改进工具的重要目标,以减少医院术前事件。这些发现有助于改进与合规性和有效沟通相关的指南技术,以提高患者术前安全性。