华西医院体外循环不良事件报告的分析

The analysis of event reports related to cardiopulmonary bypass in West China Hospital

目的总结华西医院麻醉科体外循环亚专业不良事件报告并进行根因分析,以提高心脏直视手术中体外循环管理质量。方法回顾性分析2007至2013年间心脏体外循环手术总例数以及其不良事件发生情况。结果近7年来心脏体外循环手术共12 937例,其中不良事件报告38例,不良事件发生率为1/340,体外循环对患者造成损害的不良后果发生率为1/2156,引起后遗症和死亡各2例。根因分析结果为体外循环技术人员人为因素占不良事件的39.47%,且导致的不良后果占50%;耗材因素居第二(31.58%),但无相关不良后果。结论体外循环期间人为因素是导致不良事件的主要因素,其次是耗材因素。因此,灌注人员临床技能规范化培训和制定标准化流程可有效地降低体外循环不良事件的发生率。

Objective To summarize and analyze the none-routine event reporting of cardiopulmonary bypass （ CPB） in West China Hospital, and to get informations to improve the quality of perfusion practice. Methods A retrospective study was conducted to summarize and analyze the CPB related incidents and accidents from 2007 to 2013 in West China Hospital. Results There were 12 937 cases of cardiac surgeries under CPB during the last 7 years. The total reporting none-routine events were 38 cases, and the general incidence rate was 1/340. The accidents, those incidents which had caused adverse outcome or damage to patients, happened at the rate of 1/2 156. There were 2 sequelae cases and 2 fatal cases. The most common category of incidents was perfusionist related （39.47%）, which caused 50% CPB related adverse outcome. The second category of incidents was related to disposable materials （ 31.58%） , however, without any adverse outcome. Conclusion Most CPB incidents are related to perfusionists, followed by disposables. Therefore, the clinical training of the perfusionists and the development of clinical protocols could effectively reduce the incidence of adverse events peri-CPB.