肺栓塞为损害后果的医疗事故分析与防控措施建议

Analysis of Medical Error with Pulmonary Embolism as Damage Consequence and Suggestions on Prevention and Control Measures

目的从技术鉴定角度分析肺栓塞为损害后果的医疗事故临床特征、发生机制和高危因素,提出防范措施。方法从科室分布、高危因素、事故等级、责任程度、事故原因等方面对本鉴定中心2011―2019年18例以肺栓塞为损害后果的医疗事故进行分析。结果手术科室14例,内科4例。死亡13例,植物人状态1例,好转及未愈4例。年龄、手术、创伤、肿瘤、药物等是造成肺栓塞相关事故的高危因素。经医学技术鉴定,判医疗机构有过错的14例,医方承担主要责任和次要责任,无过错的4例。对风险认识不足及不规范的预防、诊断、治疗措施是医疗事故发生的原因。结论医疗机构应警惕肺栓塞的发生,加强风险评估,采取综合预防措施有效控制肺栓塞的发病率、病死率,减少医疗纠纷和医疗事故的发生。

Objective To analyze the clinical characteristics,mechanism and high-risk factors of medical error in which pulmonary embolism is a damage consequence from the perspective of technical appraisal,and to propose preventive measures.Methods From 2011 to 2019,18 cases of medical errors with pulmonary embolism were analyzed from the aspects of department distribution,high-risk factors,accident level,degree of responsibility,and causes of the accidents.Results There were 14 cases happening in the operating department and 4 cases in the internal medicine department.13 cases died,1 case was in vegetative state,and 4 cases improved or did not heal.Age,surgery,trauma,tumor,drugs,etc.are the high-risk factors that cause pulmonary embolism-related accidents.After medical technology appraisal,14 cases were judged that the medical institution was at fault,and the medical institution should assume the primary responsibility and secondary responsibility.There were 4 cases were not at fault.Insufficient knowledge of risks and nonstandard prevention,diagnosis and treatment measures are the causes of medical accidents.Conclusion Medical institutions should be alert to the occurrence of pulmonary embolism,strengthen risk assessment,take comprehensive preventive measures to effectively control the incidence and mortality of pulmonary embolism,and reduce the occurrence of medical disputes and medical accidents.