Intraoperative Sentinel Events in the Era of Surgical Safety Checklists: Results of a National Survey.
Intraoperative Sentinel Events in the Era of Surgical Safety Checklists: Results of a National Survey.
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DOI：
10.1177/2473974x20975731
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发表时间：
2020-10
期刊：
影响因子：
1.5
通讯作者：
Brenner MJ
中科院分区：
文献类型：
--
作者：
Cramer JD;Balakrishnan K;Roy S;David Chang CW;Boss EF;Brereton JM;Monjur TM;Nussenbaum B;Brenner MJ
尽管实施了包括核对表在内的先进医疗保健安全系统，但可预防的围手术期哨兵事件仍在继续发生，并导致患者受伤、残疾和死亡。我们报告了与耳鼻喉科实践相关的发现，手术安全检查表，术中哨兵事件的范围，以及机构和个人对这些事件的反应。调查研究。对耳鼻喉科医生的匿名在线调查。美国耳鼻喉科-头颈外科学会的成员被问及术中哨兵事件、手术安全检查表实践、消防安全以及对患者安全事件的反应。总共有543名耳鼻喉科医生回答了调查(应答率为4.9%=543/11,188)。有511名(98.6%)的受访者报告使用了手术安全检查表。131名(25.2%)受访者在过去10年中报告了至少1次患者安全事件，其中最常见的是用药差错(66名(12.7%)受访者)。38名受访者(7.3%)报告了错误的地点/患者/程序事件，33名(6.4%)保留了手术物品，18名(3.5%)报告了手术室火灾。尽管414名(79.9%)的受访者认为，在案件发生前暂停是预防严重患者安全事件的唯一最有效的核对表组成部分，但一些受访者也表达了对行政负担的失望。手术安全清单被广泛应用于耳鼻咽喉科，被公认为减少患者安全事件的最有效的干预措施；然而，术中哨兵事件仍在继续发生。了解这些事件的范围、原因和响应可能有助于确定资源的优先顺序，以指导手术安全实践中的质量改进计划。
Despite the implementation of advanced health care safety systems including checklists, preventable perioperative sentinel events continue to occur and cause patient harm, disability, and death. We report on findings relating to otolaryngology practices with surgical safety checklists, the scope of intraoperative sentinel events, and institutional and personal response to these events. Survey study. Anonymous online survey of otolaryngologists. Members of the American Academy of Otolaryngology–Head and Neck Surgery were asked about intraoperative sentinel events, surgical safety checklist practices, fire safety, and the response to patient safety events. In total, 543 otolaryngologists responded to the survey (response rate 4.9% = 543/11,188). The use of surgical safety checklists was reported by 511 (98.6%) respondents. At least 1 patient safety event in the past 10 years was reported by 131 (25.2%) respondents; medication errors were the most commonly reported (66 [12.7%] respondents). Wrong site/patient/procedure events were reported by 38 (7.3%) respondents, retained surgical items by 33 (6.4%), and operating room fire by 18 (3.5%). Although 414 (79.9%) respondents felt that time-outs before the case have been the single most impactful checklist component to prevent serious patient safety events, several respondents also voiced frustrations with the administrative burden. Surgical safety checklists are widely used in otolaryngology and are generally acknowledged as the most effective intervention to reduce patient safety events; nonetheless, intraoperative sentinel events do continue to occur. Understanding the scope, causes, and response to these events may help to prioritize resources to guide quality improvement initiatives in surgical safety practices.