手术室腔镜器械不良事件原因分析及防范

Analysis and prevention of the causes of adverse events of endoscopic instruments in operating room

目的:探讨手术室腔镜器械不良事件发生的原因,根据发生的原因制定相应的防范措施,减少腔镜器械不良事件的发生。方法:统计2015年腔镜手术的例数,器械不良事件的例数和类型,并对不良事件进行分析,通过建立腔镜专业小组,制定操作流程、清洗流程,培训和考核,加强细节管理,加强交接环节器械的清点等防范措施,2016年腔镜手术器械管理严格执行此防范措施。结果:2015年腔镜手术共2 112台,发生器械不良事件16例,不良事件发生率为0. 8%; 2016年腔镜手术共2 309台,发生器械不良事件13例,不良事件发生率为0. 6%,(P> 0. 05),虽然没有统计学意义,但是2016年在总手术量和腔镜手术量增加的情况下腔镜器械不良事件减少3例,尤其是在零件脱落和器械遗失上明显减少。结论:腔镜手术不良事件有一定的发生率,根据腔镜器械不良事件发生的主要原因,及时制定严格操作流程和防范措施等,最大限度地减少不良事件发生,提高医疗护理质量。

Objective:To explore the causes of adverse events of endoscopic instruments in operating room,and formulate corresponding preventive measures according to the causes,so as to reduce and eliminate the occurrence of adverse events of endoscopic instruments.Methods:Statistics the number of endoscopic surgeny in 2015 the number and type of adverse events,and the analysis of adverse events,through the establishment of a professional team of endoscopy,the development of operating procedures,cleaning processes,training and assessment,strengthen the details of management,strengthen the transfer of equipment inventory and other preventive measures,in 2016,the instrument of endoscopic surgery strictly implemented this precautionary measure.Results:In 2015,there were 2112 endoscopic operations,16 cases of adverse events occurred,and the incidence of adverse events was 0.8%.In 2016,there were 2309 endoscopic operations,13 cases of adverse events occurred,and the incidence of adverse events was 0.6%(P>0.05).Although not statistically significant,however,in 2016,with the increase of total operative volume and the number of endoscopic operations,while the incidence of endoscopic instrument adverse events was reduced by 3 cases,especially when the part falls off and the device was lost.Conclusion:There is a certain incidence of adverse events of laparoscopic surgery,according to the main reason for the endoscopic adverse events,strict operational procedures and preventive measures should be done timely after statistical analysis,to reduce and prevent the occurrence of adverse events to the maximum extent,improve the medical quality.