手部外科常见可预防的错误：NHS 无预警事件数据的分析及一份安全检查表的建议。

Common preventable errors in hand surgery: Analysis of NHS never events data and a proposed safety checklist.

机构信息

Royal London Hospital, London, UK.

Northern Health and Social Care Trust, Antrim, UK.

出版信息

Int J Risk Saf Med. 2023;34(3):169-178. doi: 10.3233/JRS-220030.

DOI:10.3233/JRS-220030

PMID:36710688

Abstract

BACKGROUND

Hand surgical procedures are common interventions in elective and emergency settings. The complex nature of the injuries and management by multiple specialities could be a potential source of medical errors and never events (NEs). Awareness of the common NEs could potentially help prevent their occurrence in the future.

OBJECTIVE

To analyse the NHS England database to identify the common NEs in hand surgery and present a simple, practical safety checklist for hand surgery.

METHODS

The NHS NEs database from 2012 to 2021 has been analysed to identify the common hand surgery-related never events. We identified the common categories and themes within. Our theme development process is based on anatomical considerations and the nature of the incidents. Additionally, we designed a simple Safety Checklist for hand surgery.

RESULTS

We identified a total of 3742 never events with 50 incidents related to hand surgery, representing (1.3%). Wrong-site surgery was the commonest category (n = 30), representing 60% of the hand surgery-related NEs. We identified seven different themes under wrong-site surgery. Wrong finger or digit surgery was the commonest theme, with 17 reported incidents representing 57% of wrong-site surgeries. This is followed by five wrong digits injections and three wrong k wire placements representing 16.6% and 10%, respectively. The second most common category was wrong incisions (n = 15), representing 30%; 13 patients had wrong finger incisions. Two patients had carpal tunnel incisions before surgeons realised that the procedures were for trigger finger release. The third category included four wrong procedures, with two incidents of carpal tunnel release instead of trigger finger operation or Dequervain tendon release. Finally, one patient had an injection for carpal tunnel intended for another patient.

CONCLUSION

Hand surgery-related NEs represent a small fraction (1.3%) of all NEs within the NHS database. We identified 50 hand surgery-related NEs arranged into 14 different themes. Additionally, we proposed a hand surgery-specific safety checklist to reduce the incidence of these incidents in the future.

摘要

背景

手部手术是择期和急诊环境中常见的干预措施。损伤的复杂性和多个专业的管理可能是医疗错误和无预警事件（NEs）的潜在来源。了解常见的 NE 可能有助于防止它们在未来发生。

目的

分析英国国家医疗服务体系（NHS）英格兰数据库，以确定手部手术中的常见 NE，并提出一份简单实用的手部手术安全检查表。

方法

分析了 2012 年至 2021 年 NHS 的 NE 数据库，以确定与手部手术相关的常见 NE。我们确定了常见的类别和主题。我们的主题开发过程基于解剖考虑和事件的性质。此外，我们设计了一份简单的手部手术安全检查表。

结果

我们总共确定了 3742 起 NE，其中与手部手术相关的有 50 起，占 1.3%。手术部位错误是最常见的类别（n = 30），占手部手术相关 NE 的 60%。我们在手术部位错误下确定了七个不同的主题。错误手指或手指手术是最常见的主题，有 17 起报告事件，占手术部位错误的 57%。其次是五个错误的手指注射和三个错误的克氏针放置，分别占 16.6%和 10%。第二常见的类别是错误切口（n = 15），占 30%；13 名患者有错误的手指切口。两名患者在意识到手术是为了进行扳机指松解而不是腕管松解之前接受了腕管切开术。第三个类别包括四个错误的手术，其中两起是腕管松解而不是扳机指手术或 Dequervain 肌腱松解。最后，一名患者接受了用于另一名患者的腕管注射。