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手术安排表——事故一触即发?

Operating theatre lists--accidents waiting to happen?

作者信息

Reed M W, Phillips W S

机构信息

Department of Surgical & Anaesthetic Sciences, Royal Hallamshire Hospital, Sheffield.

出版信息

Ann R Coll Surg Engl. 1994 Nov;76(6 Suppl):279-80.

PMID:7598398
Abstract

Each year the Medical Defence Societies report cases where litigation has arisen due to errors in operating theatres. Incorrect details on operating lists increase the risk of such errors. The Medical Defence Societies, in conjunction with the nursing profession, have produced recommendations to reduce the risks of errors in operating theatres (1). The patient's full name and hospital number should be checked against the theatre list by the receiving nurse. Abbreviations should be avoided and operating lists should be altered as little as possible and never by telephone. Current practice in our hospital is that operating lists are typed by the consultant's secretary, using information drawn from handwritten lists submitted by junior doctors or from admission lists. Currently the final operating list is not routinely double-checked. The possibility that such a system could lead to potentially dangerous errors prompted an audit of operating lists for a one-month period, including all specialties at the Royal Hallamshire Hospital, Sheffield. The aim was to measure the incidence of errors, omissions and alterations in completed operating lists.

摘要

每年,医疗辩护协会都会报告因手术室失误而引发诉讼的案例。手术安排表上的信息错误会增加此类失误的风险。医疗辩护协会与护理行业共同提出了一些建议,以降低手术室失误的风险(1)。接收护士应将患者的全名和医院编号与手术安排表进行核对。应避免使用缩写,手术安排表应尽量少改动,且绝不能通过电话改动。我院目前的做法是,手术安排表由会诊医生的秘书根据初级医生提交的手写安排表或入院安排表中的信息进行打印。目前,最终的手术安排表通常不会进行二次核对。这样的系统可能导致潜在危险错误的可能性促使我们对谢菲尔德皇家哈勒姆郡医院一个月内的手术安排表进行了审计,涵盖所有专科。目的是衡量已完成手术安排表中的错误、遗漏和改动的发生率。

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