产科麻醉相关不良事件及质量控制分析

Obstetric anesthesia related adverse events and quality control analysis

目的通过对中国医学科学院,北京协和医学院,北京协和医院(以下简称北京协和医院)2019年1月1日至2023年12月31日产科麻醉(含分娩镇痛相关)不良事件分析,改善产科麻醉临床安全与质量。方法对北京协和医院医务处不良上报系统中与孕产妇围手术期管理相关的39例不良事件进行梳理与分析。结果近5年来,北京协和医院麻醉科共进行产科麻醉(含分娩镇痛)10218例,涉及不良事件共计39例(3.8‰),为椎管内穿刺操作相关、椎管内麻醉管理相关、并发症相关和设备耗材相关四类事件。结论不良事件的总结与质量控制分析可提高分娩镇痛及产科麻醉的临床安全水平,这种提高是通过加强科室培训及实时跟进科室管理制度达到的。

Objective To improve the clinical safety and quality of obstetric anesthesia in Peking Union Medical College Hospital,Chinese Academy of Medical Sciences&Peking Union Medical College(hereinafter referred to as Peking Union Hospital)from January 1,2019 to December 31,2023 by analyzing the adverse events related to obstetric anesthesia(including labor analgesia).Methods A total of 39 cases of adverse events related to perioperative management in the adverse reporting system of Medical Service Division,Peking Union Hospital were analyzed.Results In the past five years,a total of 10218 cases of obstetric anesthesia(including labor analgesia)were performed in Peking Union Hospital,involving 39 cases(3.8‰)of adverse events which were related to intraspinal puncture operation,intraspinal anesthesia management,complications and equipment consumables.Conclusions The summary and quality control analysis of adverse events can improve the clinical safety of labor analgesia and obstetric anesthesia,which can be achieved by strengthening department training and real-time follow-up management system.