240例手术相关未遂事件回顾分析

Retrospective analysis of 240 surgery-related near misses

目的总结手术相关未遂事件在事件构成、事件缘由、专科类别、人员配置等方面的特点,分析事件发生原因,为手术室护士对手术相关未遂事件开展前馈控制提供经验,为管理者制定手术室安全护理工作相关规范提供临床依据。方法回顾性分析2014年7月—2016年7月240例手术相关未遂事件,对计数资料采用频数、百分比进行统计描述。结果 240例手术相关未遂事件以手术缝针事件(91例,37.9%)、手术敷料事件(52例,21.7%)及手术器械事件(45例,18.8%)为主。91例手术缝针未遂事件以缝针遗失事件(40.7%,37/91)和缝针断裂事件(37.4,34/91)为主。52例手术敷料未遂事件中,手术纱布事件43例(82.7%),其中19例为再次手术患者体腔内纱布填塞数目交接不清,15例为术毕清点数目异常。45例手术器械未遂事件中,21例(46.7%)为器械断裂缺损。结论手术室护士应重点关注手术缝针遗失与断裂、手术敷料遗失及手术器械断裂缺损等事件的预防,以减少或杜绝手术相关未遂事件的发生。

Objective To summarize the characteristics of surgery-related near misses including events composition, cause of incident, specialty category, personnel allocation etc, and to provide experience of feedforward control for the nurses in operating room and a clinical basis of safety standards for the management of operating rooms. Method The 240 surgery-related near misses occurred between July 2014 and July 2016 were retrospectively analyzed, using frequencies and percentiles to describe the count data. Results The 240 surgery-related near misses were mainly associated with surgical stitches （91 cases, 37.9%）, surgical dressings （52 cases, 21.7%） and surgical instruments （45 cases, 18.8%）. The main features of the 91 cases of surgical stitching included loss of suture needles （40.7%, 37/91） and fracture events （37.4%, 34/91）. Among the 52 cases of surgical dressings, the most commonly were gauze dressing events （43 cases, 82.7%）, in which 19 were with unclear numbers of retained gauzes in the reoperation patient＇s body, and 15 were postoperative counting anomalies. Among the 45 cases of surgical instruments, the fracture and defect were the most common （21 cases, 46.7%）. Conclusion The operation nurses should focus on the prevention of suture needle loss, the surgical dressings loss and the fracture and defect of surgical instruments, etc, to reduce or avoid the surgery-related near misses.