多参数监护仪不良事件研究与患者安全对策

The study of adverse events of multi-parameter monitors and the corresponding safety countermeasures for patient

目的:探讨多参数监护仪不良事件的表现、成因和应对的措施,为临床更加安全地使用多参数监护仪提供指导方案。方法:选取医院在用的10台多参数监护仪,记录对114例患者进行监护时的设备运行情况与患者情况;分析多参数监护仪不良事件的表现,制定出相应的多参数监护仪安全管理措施。结果:在114例患者中有21例监护参数运行异常;其中,7例脉搏血氧饱和度监测运行异常(占33.33%),7例呼吸监测运行异常(占33.33%),3例无创血压监测运行异常(占14.28%),2例心电图监测运行异常(占9.52%),1例耗材配件故障(占4.76%),1例未知。15位患者出现不良事件;其中,15例"戴袖带的手臂疼痛(占13.16%)",9例"接触监护设备的皮肤出现损伤"(占7.89%),9例"报警音引起精神紧张、失眠等精神状态(占7.89%)"。结论:针对监护仪运行异常及所发生的不良事件,制定了加强质量监测与控制、及时更换耗材配件、选择不漏气的袖带及添加垫料、定期更换佩戴血氧探头的手指、设定适宜的报警音量及定期更换测量手臂等措施。

Objective： To discuss the manifestation, causation and countermeasures of adverse event of multiparameter monitor so as to provide guidance and plan for more safely using multi-parameter monitor in clinical practice. Methods： 10 multi-parameter monitors were selected and the operational situation of equipment and situation of 114 patients who were implemented monitoring were recorded. And then, the manifestation of adverse event of these monitors analyzed, and the correspondingly safe measures about multi-parameter monitor were formulated. Results： In 114 patients, the monitoring parameters of 21 cases were abnormal. And in 21 cases, the operation of pulse blood oxygen saturation（SpO_2）monitoring of 7 cases were abnormal（33.33%）, and the operation of respiration monitoring of 7 cases were abnormal（33.33%）, and the operation of non-invasive blood pressure（NIBP） monitoring of 3 cases were abnormal（14.28%）, and electrocardiography（ECG） monitoring of 2 cases were abnormal（9.52%）, and consumable accessory of 1 case was malfunction（4.76%） and 1 case was uncertain. And 15 patients suffered adverse events. Besides, arm pain was found in 15 patients who wore cuff band（13.16%）, and skin damage manifested in 9 cases who once contacted with monitoring equipment（7.89%）, and the alarm noise caused mental stress, insomnia and other mental symptoms in 9 cases（7.89%）. Conclusion： The abnormal operations of SpO_2 and respiration monitoring are the most common abnormity in the running of multi-parameter monitor, and the reasons mainly were correlation with the accessories of consumable materials.