Lipprandt Myriam, Liedtke Wenke, Langanke Martin, Klausen Andrea, Baumgarten Nicole, Röhrig Rainer
Institute of Medical Informatics, Medical Faculty, RWTH Aachen University, Aachen, Germany.
Protestant University of Applied Sciences, Bochum, Germany.
BMC Nurs. 2022 Sep 27;21(1):264. doi: 10.1186/s12912-022-01038-2.
Adverse events (AE) are ubiquitous in home mechanical ventilation (HMV) and can jeopardise patient safety. One particular source of error is human interaction with life-sustaining medical devices, such as the ventilator. The objective is to understand these errors and to be able to take appropriate action. With a systematic analysis of the hazards associated with HMV and their causes, measures can be taken to prevent damage to patient health.
A systematic adverse events analysis process was conducted to identify the causes of AE in intensive home care. The analysis process consisted of three steps. 1) An input phase consisting of an expert interview and a questionnaire. 2) Analysis and categorisation of the data into a root-cause diagram to help identify the causes of AE. 3) Derivation of risk mitigation measures to help avoid AE.
The nursing staff reported that patient transportation, suction and tracheostomy decannulation were the main factors that cause AE. They would welcome support measures such as checklists for care activities and a reminder function, for e.g. tube changes. Risk mitigation measures are given for many of the causes listed in the root-cause diagram. These include measures such as device and care competence, as well as improvements to be made by the equipment providers and manufacturers. The first step in addressing AE is transparency and an open approach to errors and near misses. A systematic error analysis can prevent patient harm through a preventive approach.
Risks in HMV were identified based on a qualitative approach. The collected data was systematically mapped onto a root-cause diagram. Using the root-cause diagram, some of the causes were analysed for risk mitigation. For manufacturers, caregivers and care services requirements for intervention offers the possibility to create a checklist for particularly risky care activities.
不良事件（AE）在家庭机械通气（HMV）中普遍存在，可能危及患者安全。一个特定的错误来源是人类与维持生命的医疗设备（如呼吸机）的交互。目的是了解这些错误并能够采取适当行动。通过对与HMV相关的危害及其原因进行系统分析，可以采取措施防止对患者健康造成损害。
进行了系统的不良事件分析过程，以确定重症家庭护理中不良事件的原因。分析过程包括三个步骤。1）输入阶段，包括专家访谈和问卷调查。2）将数据进行分析和分类，制成根本原因图，以帮助确定不良事件的原因。3）推导风险缓解措施，以帮助避免不良事件。
护理人员报告说，患者转运、吸痰和气管切开拔管是导致不良事件的主要因素。他们欢迎诸如护理活动检查表和提醒功能（如更换导管）等支持措施。针对根本原因图中列出的许多原因给出了风险缓解措施。这些措施包括设备和护理能力等方面，以及设备供应商和制造商需要改进的方面。解决不良事件的第一步是透明度以及对错误和险些失误采取开放的态度。系统的错误分析可以通过预防方法防止患者受到伤害。
基于定性方法确定了HMV中的风险。将收集到的数据系统地映射到根本原因图上。利用根本原因图，对一些原因进行了风险缓解分析。对于制造商、护理人员和护理服务机构来说，干预要求提供了为特别危险的护理活动创建检查表的可能性。
