重症监护室不良事件报告现状分析和应对策略

Status and Countermeasures of Adverse Events Report in Intensive Care Units

目的分析国内外重症监护室不良事件的发生和报告情况,为提高医疗质量提供参考。方法对国外重症监护室不良事件报告情况进行文献分析,对国内某三甲医院重症监护室9年共194例不良事件报告进行数据分析。结果研究发现,国外重症监护室不良事件发生率明显高于医院整体不良事件发现率,研究主要集中于儿童和老年人群体以及外科病人。国内数据表明,重症监护室不良事件集中于50岁以上人群,拔管事件、并发症和其它事件是3大主要类型。结论国内医院需要设计分类成熟的不良事件报告系统鼓励报告不良事件,以更好地保障重症监护室病人安全。

Objective To analyze domestic and international evidences on adverse events in Intensive Care Units （ICU）, and provide references for medical quality improvement. Method Review on international literatures on adverse events in ICU was performed, and a total of 194 cases of adverse events in ICU of a Three - A hospital were analyzed. Result Foreign evidences showed that the incidence of adverse events in ICU was higher than that in other units, and the majority of the evidences were fo- cused on children, the elderly, and surgical patients. Data analysis in a hospital in China showed that most adverse events in ICU were in patients with more than 50 years old, and the major adverse events were extubation event, complications and other types. Conclusion An encouraging reporting system with valid classification is needed to ensure the medical safety of patients in ICU.