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Preliminary Report of Non-punitive Reporting of Perioperative Adverse Events in Peking Union Medical College Hospital during 2010—2014
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摘要:
目的 对手术麻醉不良事件进行归纳、总结，旨在提高临床麻醉的安全性。 方法 回顾性分析2010年1月—2014年12月北京协和医院麻醉科上报的所有《不良事件和患者安全隐患报告》。采用鱼骨图法对不良事件发生的根本原因、时机、可避免性以及是否对患者造成伤害等进行分析、总结。 结果 共上报不良事件370例，其发生的根本原因主要是人为因素(43.08%，224/520)，其次为系统因素(30.96%，161/520)，患者因素占比最低(25.96%，135/520);44例(11.89%，44/370)为急诊手术，37例(10.00%，37/370)发生在夜间，243例(65.68%，243/370)可避免。根据发生时机的不同，不良事件发生率前4位由高至低依次为术中(28.11%，104/370)、麻醉诱导前(17.30%，64/370)、麻醉诱导期间(13.78%，51/370)、手术结束复苏时(12.97%，48/370)。80例(21.62%，80/370)不良事件未对患者造成伤害，262例(70.81%，262/370)造成暂时性轻微伤害，15例(4.05%，15/370)造成永久性伤害，13例(3.51%，13/270)导致患者术中/术后24 h内发生非麻醉相关死亡。与可避免不良事件比较，不可避免不良事件发生的根本原因中患者因素占比(60.26%比11.26%，P＜0.001)、造成患者术中/术后24 h内发生非麻醉相关死亡的占比(8.66%比0.82%，P＜0.001)均增高。 结论 2010—2014年北京协和医院手术麻醉不良事件发生的根本原因主要是人为因素和系统因素，多数可避免且对患者仅造成暂时轻微伤害。通过对不良事件进行反馈学习，加强人员培训、优化系统条件，对降低麻醉不良事件发生率具有重要意义。 Abstract:Objective o optimize the system conditions and improve the patients' perioperative surgical safety through feedback learning for adverse events. Methods We retrospectively analyzed the adverse events (AEs) and risks of patients' safety reported by the Department of Anesthesiology, Peking Union Medical College Hospital from January 2010 to December 2014. Fish bone diagram was used to analyze and summarize the root causes, timing, avoidability and injury from adverse events. Results A total of 370 cases of AEs were collected. The root causes of AEs were mainly human factors (43.08%, 224/520), followed by systemic factors (30.96%, 161/520), and patient factors were the lowest (25.96%, 135/520). Forty-four cases (11.89%, 44/370) were emergent operations; 37 cases (10.00%, 37/370) occurred at night; 243 cases (65.68%, 243/370) could be avoided. According to the different occurrence time, the top four incidence rates were intraoperative (28.11%, 104/370), before anesthesia induction (17.30%, 64/370), during anesthesia induction (13.78%, 51/370), and at the end of surgery (12.97%, 48/370). Eighty AEs (21.62%, 80/370) did not cause injury; 262 cases (70.81%, 262/370) caused temporary minor injury; 15 cases (4.05%, 15/370) caused permanent injury; 13 cases (3.51%, 13/270) caused non-anesthesia related death intraoperatively or within 24 hours after the surgery. Compared with avoidable AEs, the proportion of patient factors (60.26% vs. 11.26%, P < 0.001) and that of non-anesthesia related death intraoperatively or within 24 hours after the surgery (8.66% vs. 0.82%, P < 0.001) in the unavoidable group were higher. Conclusions The root causes of perioperative AEs are mainly human factors, most of which can be avoided and cause temporary mild injury to patients. Strengthening feedback learning of AE, improving personnel training and optimizing system conditions might reduce the incidence of AE and promote perioperative safety and quality. -
Key words:
- surgery /
- anesthesia /
- adverse events /
- non-punitive incident reporting /
- root cause analysis
作者贡献：朱波负责数据分析、论文撰写与修改; 张砡负责数据整理分析; 张秀华、黄宇光负责审核; 冯雪辛负责数据统计分析。利益冲突：无 -
表 1 不良事件鱼骨图法分析表
项目(勾选，发生根本原因可多选) 1.发生根本原因 (1)人为因素 A.麻醉医师经验不足、不熟悉机器性能、操作不熟练 B.手术操作问题、手术医师对患者整体情况判断不足 C.人员交流不畅 D.过于匆忙 E.注意力分散 F.疲劳 G.缺乏责任心 H.人力不足 (2)患者因素 A.是 B.否 (3)系统因素 A.缺乏风险防范措施 B.机械故障，机器或计算机系统设计不合理 C.科室间协作有问题 2.是否可避免 A.是 B.否 3.对患者造成伤害 A.未造成伤害 B.暂时性轻微伤害 C.永久性伤害 D.导致患者术中/术后24 h内发生非麻醉相关死亡 4.发生时机 A.麻醉诱导前 B.麻醉诱导期间 C.手术开始时 D.术中 E.手术结束复苏时 F.术后恢复室 G.转运过程中 H.与ICU交接或在ICU内 I.手术结束后返回病房或术后若干天 J.不适用 5.发生时间 A.白天 B.夜间 C.未记录 6.是否急诊手术 A.是 B.否 
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表 2 不良事件发生的根本原因比较[n(%)]
指标 根本原因(n) 患者因素 系统因素 人为因素 可避免不良事件(n=243) 364 41(11.26) 147(40.38) 176(48.35) 不可避免不良事件(n=127) 156 94(60.26) 14(8.97) 48(30.77) P值 ＜0.001 ＜0.001 ＜0.001
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表 3 不良事件对患者造成损害的类型比较[n(%)]
指标 无伤害 暂时性轻微伤害 永久性伤害 患者死亡 可避免不良事件(n=243) 68(27.98) 166(68.31) 7(2.88) 2(0.82) 不可避免不良事件(n=127) 12(9.45) 96(75.59) 8(6.30) 11(8.66) P值 ＜0.001 0.144 0.113 ＜0.001
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