Incidents relating to the intra-hospital transfer of critically ill patients - An analysis of the reports submitted to the Australian Incident Monitoring Study in Intensive Care
Incidents relating to the intra-hospital transfer of critically ill patients - An analysis of the reports submitted to the Australian Incident Monitoring Study in Intensive Care
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DOI：
10.1007/s00134-004-2177-9
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发表时间：
2004-08-01
影响因子：
38.9
通讯作者：
Pronovost, P
中科院分区：
文献类型：
--
作者：
Beckmann, U;Gillies, DM;Pronovost, P
Objective.在医院内运送危重病人会带来重大风险。我们试图确定与医院内运输相关的原因、结果和影响因素。设计横向案例审查。设置.提交给澳大利亚重症监护事件监测研究（AIMS-ICU）的事件报告。测量和主要结果。1993年至1999年期间，共提交了176份报告，叙述了191起事件。75份报告（39%）确定了设备问题，主要涉及电池/电源、输送呼吸机和监护仪功能、患者升降机和插管设备的使用。116份报告（61%）确定了患者/工作人员管理问题，包括沟通不良、监测不充分、设备设置不正确、人工气道错位和患者定位不正确。55份报告（31%）发生了严重不良结局，包括严重生理紊乱（15%）、患者/亲属不满（7%）、住院时间延长（4%）、身体/心理损伤（3%）和死亡（2%）。在确定的900个影响因素中，46%是基于系统的，54%是基于人为的。通信问题、规程不足、在职/培训和设备是与设备有关的突出事件。问题识别和判断错误、不遵守协议、患者准备不足、匆忙和疏忽是常见的管理相关事件。重新检查患者和设备、技术援助和既往经验是限制伤害的重要因素。结论.院内转运对ICU患者构成重要风险。充分提供高素质的工作人员、专门设计和维护良好的设备以及持续监测，对于避免/减轻这些事件至关重要。专业协会和当地单位应采用医院内运输的指南/协议。事件监测应有助于持续改善患者安全。
Objective. Transportation of critically ill patients within the hospital poses important risks. We sought to identify causes, outcomes and contributing factors associated with intra-hospital transport. Design. Cross-sectional case review. Setting. Incident reports submitted to the Australian Incident Monitoring Study in Intensive Care (AIMS-ICU). Measurement and main results. Between 1993 and 1999, 176 reports were submitted describing 191 incidents. Seventy-five reports (39%) identified equipment problems, relating prominently to battery/power supply, transport ventilator and monitor function, access to patient elevators and intubation equipment. Hundred sixteen reports (61%) identified patient/staff management issues including poor communication, inadequate monitoring, incorrect set-up of equipment, artificial airway malpositioning and incorrect positioning of patients. Serious adverse outcomes occurred in 55 reports (31%) including major physiological derangement (15%), patient/relative dissatisfaction (7%), prolonged hospital stay (4%), physical/psychological injury (3%) and death (2%). Of 900 contributing factors identified, 46% were system-based and 54% human-based. Communication problems, inadequate protocols, in-servicing/training and equipment were prominent equipment-related incidents. Errors of problem recognition and judgement, failure to follow protocols, inadequate patient preparation, haste and inattention were common management-related incidents. Rechecking the patient and equipment, skilled assistance and prior experience were important factors limiting harm. Conclusions. Intra-hospital transport poses an important risk to ICU patients. The adequate provision of highly qualified staff, specially designed and well maintained equipment, as well as continuous monitoring are essential to avoid/mitigate these incidents. Professional societies and local units should adopt guidelines/protocols for intra-hospital transportation. Monitoring of incidents should aid in the continuous improvement in patient safety.