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Incident reporting in post-operative patients managed by acute pain service

机译:由急性疼痛服务治疗的术后患者的事件报告

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Background and Aims: Incident reporting is a reliable and inexpensive tool used in anaesthesia to identify errors in patient management. A hospital incident reporting system was already present in our hospital, but we were unable to find any incident related to acute pain management. Hence, acute pain service (APS) was started for voluntary incident reporting in post-operative patients to identify critical incidents, review the root cause and suggest remedial measures. Methods: All post-operative patients managed by APS were included in this observational study. A proforma was developed by APS, which included information about the type of incident (equipment and patient-related, human errors), severity of incident, person responsible and suggestions to prevent the same incident in the future. Patients and medical staff were informed about the reporting system. Whenever an incident was identified, a proforma was filled out by APS resident and data entered in SPSS programme. Results: Total of 98 (1.80%) incidents were reported in 5432 patients managed by APS during 3 years period. Average age of the patients was 46 ± 17 years. Majority of incidents were related to epidural care (71%) and occurred in surgical wards (87%). Most of the incidents occurred due to human error and infusion delivery set-related defects. Conclusion: Incident reporting proved to be a feasible method of improving quality care in developing countries. It not only provides valuable information about areas which needed improvement, but also helped in developing strategies to improve care. Knowledge and attitudes of medical and paramedical staff are identified as the targeted area for improvement.
机译:背景和目的:事件报告是麻醉中用于识别患者管理错误的可靠且廉价的工具。我们医院已经有一个医院事故报告系统,但是我们找不到与急性疼痛管理有关的任何事故。因此,开始为患者术后的自愿事件报告提供急性疼痛服务(APS),以识别关键事件,检查根本原因并提出补救措施。方法:本研究纳入了所有由APS治疗的术后患者。 APS开发了一个备考表,其中包括有关事故类型(设备和与患者相关的,人为错误),事故严重性,负责人以及未来预防同一事故的建议的信息。患者和医务人员被告知报告系统。一旦发现事故,APS居民将填写一份备考表,并将数据输入SPSS计划。结果:在3年的时间里,APS管理的5432例患者总共报告了98例(1.80%)事件。患者的平均年龄为46±17岁。多数事件与硬膜外护理有关(71%),且发生在外科病房(87%)。大多数事件是由于人为错误和输注设备相关的缺陷而发生的。结论:事件报告被证明是改善发展中国家优质医疗服务的可行方法。它不仅提供了有关需要改进的方面的有价值的信息,而且还帮助制定了改善护理的策略。医务人员和护理人员的知识和态度被确定为需要改进的领域。

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