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提高患者安全:识别手术室患者转运期间的跌倒风险。

Enhancing patient safety: identifying fall risks during patient transfers in operating rooms.

作者信息

Okuyucu Kübra

机构信息

Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Amasya University, İpekköy Campus, Amasya, 05100, Turkey.

出版信息

BMC Health Serv Res. 2025 Apr 16;25(1):557. doi: 10.1186/s12913-025-12750-5.

Abstract

BACKGROUND

Transfers within operating rooms present significant risks to patient safety, with falls potentially leading to serious consequences for both patients and staff. The aim of this study is to explore the factors contributing to falls during transfers and strategies to enhance patient safety in operating rooms.

METHODS

This is a qualitative study conducted using semi-structured interviews with fifteen operating room staff including nurse (n = 7), anaesthesia technician (n = 7) and scrub person (n = 1). Their ages ranged from 28 to 39 years, with experience years in the operating room ranging from two to ten years. The data were analysed using a thematic analysis approach based on the grounded theory.

RESULTS

The thematic analysis identified six key factors contributing to falls during patient transfers: human error, team coordination, patient condition, staffing challenges, equipment issues, and inadequate training. Participants recommended improving team collaboration, pre-operative patient education, better infrastructure (e.g., private elevators), hands-on training, and increased staffing. Additionally, policy changes to limit complex outpatient transfers were suggested to reduce risks.

CONCLUSIONS

This study provides valuable insights into the risk factors and potential prevention strategies regarding falls during patient transfers in operating rooms. Future research should incorporate multidisciplinary observational studies involving human factors to provide deeper insights. It is recommended to create systems for anonymous incident reporting and implement comprehensive training programs.

摘要

背景

手术室内部的患者转运对患者安全构成重大风险,跌倒可能会给患者和工作人员带来严重后果。本研究的目的是探讨导致转运期间跌倒的因素以及提高手术室患者安全的策略。

方法

这是一项定性研究,采用半结构化访谈对15名手术室工作人员进行,包括护士(n = 7)、麻醉技术员(n = 7)和刷手护士(n = 1)。他们的年龄在28岁至39岁之间,在手术室的工作经验为2至10年。数据采用基于扎根理论的主题分析方法进行分析。

结果

主题分析确定了导致患者转运期间跌倒的六个关键因素:人为失误、团队协作、患者状况、人员配备挑战、设备问题和培训不足。参与者建议改善团队协作、术前患者教育、更好的基础设施(如专用电梯)、实践培训和增加人员配备。此外,建议进行政策调整以限制复杂的门诊患者转运,以降低风险。

结论

本研究为手术室患者转运期间跌倒的风险因素和潜在预防策略提供了有价值的见解。未来的研究应纳入涉及人为因素的多学科观察性研究,以提供更深入的见解。建议建立匿名事件报告系统并实施全面的培训计划。

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本文引用的文献

1
Perioperative Nursing Shortages: An Integrative Review of Their Impact, Causal Factors, and Mitigation Strategies.
J Nurs Manag. 2024 Aug 19;2024:2983251. doi: 10.1155/2024/2983251. eCollection 2024.
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Patient Falls in the Operating Room: Why Is This Still a Problem in 2024?
J Patient Saf. 2024 Sep 1;20(6):e87-e90. doi: 10.1097/PTS.0000000000001248. Epub 2024 Jun 28.
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Patient falls in the operating room setting: An analysis of reported safety events.
J Healthc Risk Manag. 2022 Jul;42(1):9-14. doi: 10.1002/jhrm.21503. Epub 2022 Apr 1.
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J Neurosurg. 2021 Sep 24;136(4):1157-1163. doi: 10.3171/2021.4.JNS21485. Print 2022 Apr 1.
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Case Analysis of Factors Contributing to Patient Falls.
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