加强手术管理 确保病人安全课件

1、加强手术管理 确保手术安全北京协和医院麻醉科 朱斌 黄宇光基本内容10个存在的事实/问题10个基本目标应对手段-手术安全核对表我们面临的危机-危险与机遇事实 1在全球各地，每年施行的大手术约有2.34亿例。这相当于每25人中约有1人接受手术。 每年有6300万人通过手术治疗外伤，1000万人通过手术治疗妊娠相关的并发症，3100多万人通过手术治疗癌症。 事实 2研究表明，手术后并发症可导致3-25%患者残疾或延长住院时间 。这意味着每年至少有700万患者可能遭受术后并发症，而其中一半是可以预防的。事实 3根据具体情况不同，大手术后的死亡率一般在0.4%至10%之间不等。根据对这些死亡率影响的评

2、估，每年至少有100万患者在手术过程中或手术后死亡。 事实 5在发达国家中，影响医院患者的所有有害事件（如交流不当、用错药及技术错误等）几乎半数都与外科治疗和服务有关。证据表明，如果遵守治疗规范并使用核对表之类的安全流程，这类事件至少有一半是可以预防的。事实 6在发展中国家的环境下，外科治疗已被证明 具有明显的成本效益。确保治疗安全，只会提高其疗效 。外科病房中一名小孩左腿手术中恢复事实 8在手术中，甚至在复杂情况下采取的安全措施都是不一致的。采取简单步骤即可降低并发症发生率。 例如，改进在切皮之前使用抗生素的时间及选择，可降低外科手术部位感染率达50%。 印度一家医院中正在实施一项外科手术事

3、实 9世卫组织已制定了适用于各国卫生情况的 手术安全指导原则(Safe surgery guidelines)和 手术安全核对表（Surgical safety checklist）。在全球八个示范点的初步结果表明，由于使用了该核对表，患者获得标准外科治疗的可能性加倍，这包括： 在切开皮肤之前使用抗生素， 确认为正确的病人在正确的部位实施正确的手术。事实 10目前WHO正在与200多个卫生部、国家和国际医学协会以及专业组织合作开展“加强手术管理、确保手术安全”的行动，以期减少外科治疗中死亡人数和并发症。正确的病人、正确的部位、正确的手术在美国，每年大约有1500-2500例手术部位错误事件发生

4、。一份对1050名手外科医生的调查问卷显示：21%医生承认在他们的职业生涯中至少发生过一起手术部位错误的事件。Seiden, Archives of Surgery, 2006. Joint Commission, Sentinel Event Statistics, 2006.目标 2使用已知的合适方法，既要让病人处于无痛状态，又要防止麻醉所引起的伤害。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.目标 4知晓并有效地准备，应对手

6、术期间可能出现的大量失血。 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.目标 5事先了解病人用药史，避免术中诱发药物过敏或药物不良反应。 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.目标 6采用已知可行的方法，减少手术部位感染风险 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.目标 7避免在手术切口内遗留任何器械或纱布。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.目标 8妥善保存并准确识别所有取之于病人手术标本 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.目标 9有效沟通和交流与手术安全相关的所有重要信息 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初步结果发现：术后并发症发生率和死亡率降低超过1/3！ N Engl J Med 2009;360:491-9.国内有关手术安全标准的尝试2007年患者安全目标，其中目标之五就明确提出：“严格防止手术