加強手術(shù)管理 確保病人安全課件

1、加強手術(shù)管理 確保手術(shù)安全北京協(xié)和醫(yī)院麻醉科 朱斌 黃宇光基本內(nèi)容10個存在的事實/問題10個基本目標(biāo)應(yīng)對手段-手術(shù)安全核對表我們面臨的危機-危險與機遇事實 1在全球各地，每年施行的大手術(shù)約有2.34億例。這相當(dāng)于每25人中約有1人接受手術(shù)。 每年有6300萬人通過手術(shù)治療外傷，1000萬人通過手術(shù)治療妊娠相關(guān)的并發(fā)癥，3100多萬人通過手術(shù)治療癌癥。 事實 2研究表明，手術(shù)后并發(fā)癥可導(dǎo)致3-25%患者殘疾或延長住院時間 。這意味著每年至少有700萬患者可能遭受術(shù)后并發(fā)癥，而其中一半是可以預(yù)防的。事實 3根據(jù)具體情況不同，大手術(shù)后的死亡率一般在0.4%至10%之間不等。根據(jù)對這些死亡率影響的評

2、估，每年至少有100萬患者在手術(shù)過程中或手術(shù)后死亡。 事實 5在發(fā)達國家中，影響醫(yī)院患者的所有有害事件（如交流不當(dāng)、用錯藥及技術(shù)錯誤等）幾乎半數(shù)都與外科治療和服務(wù)有關(guān)。證據(jù)表明，如果遵守治療規(guī)范并使用核對表之類的安全流程，這類事件至少有一半是可以預(yù)防的。事實 6在發(fā)展中國家的環(huán)境下，外科治療已被證明 具有明顯的成本效益。確保治療安全，只會提高其療效 。外科病房中一名小孩左腿手術(shù)中恢復(fù)事實 8在手術(shù)中，甚至在復(fù)雜情況下采取的安全措施都是不一致的。采取簡單步驟即可降低并發(fā)癥發(fā)生率。 例如，改進在切皮之前使用抗生素的時間及選擇，可降低外科手術(shù)部位感染率達50%。 印度一家醫(yī)院中正在實施一項外科手術(shù)事

3、實 9世衛(wèi)組織已制定了適用于各國衛(wèi)生情況的 手術(shù)安全指導(dǎo)原則(Safe surgery guidelines)和 手術(shù)安全核對表（Surgical safety checklist）。在全球八個示范點的初步結(jié)果表明，由于使用了該核對表，患者獲得標(biāo)準(zhǔn)外科治療的可能性加倍，這包括： 在切開皮膚之前使用抗生素， 確認為正確的病人在正確的部位實施正確的手術(shù)。事實 10目前WHO正在與200多個衛(wèi)生部、國家和國際醫(yī)學(xué)協(xié)會以及專業(yè)組織合作開展“加強手術(shù)管理、確保手術(shù)安全”的行動，以期減少外科治療中死亡人數(shù)和并發(fā)癥。正確的病人、正確的部位、正確的手術(shù)在美國，每年大約有1500-2500例手術(shù)部位錯誤事件發(fā)生

4、。一份對1050名手外科醫(yī)生的調(diào)查問卷顯示：21%醫(yī)生承認在他們的職業(yè)生涯中至少發(fā)生過一起手術(shù)部位錯誤的事件。Seiden, Archives of Surgery, 2006. Joint Commission, Sentinel Event Statistics, 2006.目標(biāo) 2使用已知的合適方法，既要讓病人處于無痛狀態(tài)，又要防止麻醉所引起的傷害。Arbous, M. S., A. E. Meursing, et al. (2005). Impact of anesthesia management characteristics on severe morbidity and mor

5、tality. Anesthesiology 102: 257-68.Hodges, S. C., C. Mijumbi, et al. (2007). Anaesthesia services in developing countries: defining the problems. Anaesthesia 62(1): 4-11.Runciman, W. B. (2005). Iatrogenic harm and anaesthesia in Australia. Anaesthesia & Intensive Care 33(3): 297-300.目標(biāo) 4知曉并有效地準(zhǔn)備，應(yīng)對手

6、術(shù)期間可能出現(xiàn)的大量失血。 American College of Surgeons: Committee on Trauma (1997). Advanced Trauma Life Support for Doctors. Chicago, ACS.Feliciano, D., K. Mattox, et al. (2008). Trauma. New York, McGraw Hill.Gaba, D. M., K. J. Fish, et al. (1994). Crisis Management in Anesthesiology. New York, Churchill Livin

7、gston.Rivers, E., B. Nguyen, et al. (2001). Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 345(19): 1368-77.目標(biāo) 5事先了解病人用藥史，避免術(shù)中誘發(fā)藥物過敏或藥物不良反應(yīng)。 Baker, G. R., P. G. Norton, et al. (2004). The Canadian Adverse Events Study: the incidence of adverse events amo

8、ng hospital patients in Canada. CMAJ Canadian Medical Association Journal 170(11): 1678-86.Bowdle, T. A. (2003). Drug administration errors from the ASA Closed Claims Project. ASA Newsletter 67: 11-3.Jensen, L. S., A. F. Merry, et al. (2004). Evidence-based strategies for preventing drug administrat

9、ion errors during anaesthesia. Anaesthesia 59(5): 493-504.Wheeler, S. J. and D. W. Wheeler (2005). Medication errors in anaesthesia and critical care. Anaesthesia 60(3): 257-73.目標(biāo) 6采用已知可行的方法，減少手術(shù)部位感染風(fēng)險 Bratzler, D. W., P. M. Houck, et al. (2005). Use of antimicrobial prophylaxis for major surgery: b

10、aseline results from the national surgical infection prevention project. Arch Surg 140(2): 174-82.Dellinger, E. P. (2007). Prophylactic antibiotics: administration and timing before operation are more important than administration after operation. Clin Infect Dis 44(7): 928-30.Rioux, C., B. Grandbas

11、tien, et al. (2007). Impact of a six-year control programme on surgical site infections in France: results of the INCISO surveillance. J Hosp Infect 66(3): 217-23.目標(biāo) 7避免在手術(shù)切口內(nèi)遺留任何器械或紗布。American College of Surgeons. American College of Surgeons: Statement on the Prevention of Retained Foreign Bodies

12、after Surgery. Retrieved 5 February, 2008, from /fellows_info/statements/st-51.html.Australian College of Operating Room Nurses and Association of peri-Operative Registered Nurses (2006). Counting of Accountable Items used during Surgery. Standards for Perioperative Nurses. ACORN: 1-12.Gawande, A. A

13、., D. M. Studdert, et al. (2003). Risk factors for retained instruments and sponges after surgery. N Engl J Med 348(3): 229-35.目標(biāo) 8妥善保存并準(zhǔn)確識別所有取之于病人手術(shù)標(biāo)本 Howanitz, P. J. (2005). Errors in laboratory medicine: practical lessons to improve patient safety. Arch.Pathol.Lab Med. 129(10): 1252-1261.Makary,

14、M. A., J. Epstein, et al. (2007). Surgical specimen identification errors: a new measure of quality in surgical care. Surgery 141(4): 450-455.Troxel, D. B. (2004). Error in surgical pathology. Am.J.Surg.Pathol. 28(8): 1092-1095.Wagar, E. A., L. Tamashiro, et al. (2006). Patient safety in the clinica

15、l laboratory: a longitudinal analysis of specimen identification errors. Arch.Pathol.Lab Med. 130(11): 1662-1668.目標(biāo) 9有效溝通和交流與手術(shù)安全相關(guān)的所有重要信息 Greenberg, C. C., S. E. Regenbogen, et al. (2007). Patterns of communication breakdowns resulting in injury to surgical patients. J Am Coll Surg 204(4): 533-40.L

16、ingard, L., S. Espin, et al. (2005). Getting teams to talk: development and pilot implementation of a checklist to promote interprofessional communication in the OR. Qual.Saf Health Care 14(5): 340-346.Lingard, L., G. Regehr, et al. (2008). Evaluation of a preoperative checklist and team briefing am

17、ong surgeons, nurses, and anesthesiologists to reduce failures in communication. Arch Surg 143(1): 12-7; discussion 18.Makary, M. A., A. Mukherjee, et al. (2007). Operating room briefings and wrong-site surgery. J.Am.Coll.Surg. 204(2): 236-243.Pronovost, P., D. Needham, et al. (2006). An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 355(26): 2725-32.NEWS LETTER2008-12初步結(jié)果發(fā)現(xiàn)：術(shù)后并發(fā)癥發(fā)生率和死亡率降低超過1/3！ N Engl J Med 2009;360:491-9.國內(nèi)有關(guān)手術(shù)安全標(biāo)準(zhǔn)的嘗試2007年患者安全目標(biāo)，其中目標(biāo)之五就明確提出：“嚴(yán)格防止手術(shù)