Equipment problems during anaesthesia - are they a quality problem?
Equipment problems during anaesthesia - are they a quality problem?
复制标题
DOI：
10.1093/bja/aef276
复制
发表时间：
2002-12-01
影响因子：
9.8
通讯作者：
Gisvold, SE
中科院分区：
文献类型：
--
作者：
Fasting, S;Gisvold, SE
背景麻醉设备问题可能导致麻醉发病率和死亡率。这些问题的严重程度和模式尚未确定。我们想分析我们部门设备相关问题的频率、类型和严重程度，以及是否需要采取额外措施来提高安全性。这项研究是基于一个系统，在该系统中，麻醉相关的数据记录从所有麻醉病例的常规基础上。数据包括术中问题及其严重程度。当问题发生时，负责该病例的麻醉师在麻醉表上写下事件的简短描述。从所有记录的全身麻醉和区域麻醉病例中，我们选择了记录有麻醉“设备/技术问题”的病例。这些图表是从部门档案中检索出来进行分析的。从83154麻醉，我们发现的频率麻醉设备的问题是0.05%，在区域麻醉，全身麻醉过程中的0.23%。三分之一的问题涉及麻醉机，四分之一涉及人为错误。无患者死亡，无患者发生任何持续性疾病。设备问题的发生率很低，而且往往不严重。除了改进术前设备检查程序外，没有提出减少问题的具体策略。设备问题的发生率并不是一个很好的质量指标，因为发生率很低。然而，记录的设备问题可能有助于提高质量，通过分析成因，并提出预防策略。
Background. Anaesthesia equipment problems may contribute to anaesthetic morbidity and mortality. The magnitude and pattern of these problems are not established. We wanted to analyse the frequency, type and severity of equipment-related problems in our department, and if additional efforts to improve safety were needed.Methods. The study is based on a system in which anaesthesia-related data are recorded from all anaesthetic cases on a routine basis. The data include intraoperative problems and their severity. When a problem occurs, the anaesthetist responsible for the case writes a short description of the event on the anaesthetic chart. From all recorded cases of general and regional anaesthesia, we selected cases recorded with anaesthetic 'equipment/technical problems'. These charts were retrieved from departmental archives for analysis.Results. From 83 154 anaesthetics, we found the frequency of anaesthetic equipment problems to be 0.05% during regional anaesthesia, and 0.23% during general anaesthesia. One-third of problems involved the anaesthesia machine, and in a quarter, human error was involved. No patient died and none suffered any lasting morbidity.Conclusion. The rate of equipment problems was low, and most often of low severity. Aside from improvements in routines for preoperative equipment checks, no specific strategies for problem reduction could be suggested. The incidence of equipment problems is not a good quality indicator because of the low rate of occurrence. However, recorded equipment problems may be useful for improving quality, by analysing causative factors, and suggesting preventative strategies.