非手术类侵入性操作异物遗留不良事件的分析与改进

Analysis and Improvement of Adverse Events Left by Foreign Bodies During Non-Surgical Invasive Operations

目的对非手术类侵入性操作造成异物遗留患者体内的不良事件进行研究,分析相关数据及原因,为降低该类不良事件的发生提出改进策略。方法对2020年1月—2023年12月四川大学华西医院的14例非手术类侵入性操作异物遗留不良事件进行统计分析。结果非手术类侵入性操作异物遗留一旦发生多为Ⅱ级不良事件,患者损害程度F级,大多需要通过手术取出异物。异物遗留不良事件78.57%发生在工作日,主要集中在穿刺置管类,血管发生异物遗留的例数远高于其他部位。50岁以上的患者占71.43%,初级职称医务人员占92.86%,其中操作不规范占50.00%、操作前后未核对占42.86%,缺乏上级医师指导带教和双人核查流程,患者及家属参与度低。结论医院应从合理配置人力资源、加强初级职称医务人员技能培训、提高上级医师责任意识、完善非手术类侵入性操作标准流程及管理规范、加强异物遗留危急值管理、强化考核与分析整改、严格把控进院医疗耗材质量、改善诊疗环境、鼓励患者参与医疗、构建患者安全文化等方面着手落实,避免发生非手术类侵入性操作异物遗留患者体内的不良事件,保障患者安全。

Objective Adverse events in patients with foreign bodies left behind by non-surgical invasive operations were studied,relevant data and causes were analyzed,and improved strategies were proposed to reduce the occurrence of such adverse events.Methods A statistical analysis was conducted on 14 cases of non surgical invasive foreign body residual adverse events in West China Hospital,Sichuan University from January 2020 to December 2023.Results Non-surgical invasive procedures often result in GradeⅡadverse events when foreign bodies are left behind,and the degree of damage to patients is Grade F,requiring surgical removal of foreign bodies.78.57%of adverse events related to foreign body remnants occurred on weekdays,mainly concentrated in puncture catheterization.The number of cases of foreign body remnants in blood vessels was much higher than in other areas.71.43%of patients are over 50 years old,and 92.86%are medical personnel with junior professional titles.Among them,50.00%have non-standard operations and 42.86%have not been verified before and after operations,lack of guidance and teaching by superior doctors and double verification process,low participation of patients and their families.Conclusion Hospitals should start implementing measures such as rational allocation of human resources,strengthening skill training for junior medical personnel,enhancing the sense of responsibility of higher-level physicians,improving the standard process and management norms for non surgical invasive operations,strengthening the management of critical values for foreign body residues,strengthening assessment and analysis,strictly controlling the quality of medical consumables entering the hospital,improving the diagnosis and treatment environment,encouraging patients to participate in medical treatment,and building a patient safety culture,in order to avoid adverse events caused by foreign body residues in non surgical invasive operations and ensure patient safety.