质量控制安全性策略（课件）

ICU质量控制 安全性策略,解放军总医院第二附属医院ICU,马朋林,提 纲,ICU 安全性现状 不安全因素分析 提高安全性对策,一、ICU 安全性现状,6 SIGMA 管理,PPM=3.4 百万次操作 错误发生 3.4次,ICU质量评定,操作次数： 10003000次/病人/天 观察、处理报警、监测、治疗 可预防错误：36个/1000病人.天 PPM=12-36 威胁病人生命错误：占13% =4.7个/1000病人.天。 PPM=1.5-4.7,Data from Jeffrey CCM 2005,ICU 百万分安全？,工业产品=生命？ ICU质量控制目标 医疗错误相关死亡率 PPM=0,How Hazardous Is Health Care?,Lakshmi Halasyamani, MD, Michigan,“To Err Is Human”,Errors caused Deaths In US: 44000-98000 /Year Kohn, Institute of Medicine 1999 In China: 12900/year ? Adopted from CAC 1999,Errors Happened in ICU,Critical Care Safety Study 391 patients (1 year) 1490 patient-days 277 errors 11% Life-threatening Jeffrey M CCM 2005,Admitted,Refused,ICU与普通病房区别,Simchen E et al. Crit Care Med 2004; 32:1654-1661,159 cases,二、不安全因素分析,ICU不安全因素,ICU环境因素 人力资源短缺 病人因素 管理因素,ICU环境引起病人心理状态改变,不仅只有病人紧张,Burnout in intensive care unit Minerva Anesthesiol 2007 Apr;73(4):195-200,Am J Respir Crit Care Med. 2007 ;175(7):698-704.,Intensive care med;2008 Jan;34(1):152-6,Burnout contagion among intensive care nurses J Adv Nurs. 2005 Aug;51(3):276-87.,是医疗错误的重要原因之一,HAP 普通病房：5% ICU: 1520%,ICU环境增加院内感染,人力资源短缺是医疗错误发生的独立高危因素,Medical errors in relation to staff work hours in ICU,NEJM, 2004,护士人力资源短缺与ICU错误,Hospital mortality in relation to staff workload: a 4-year study in ICU,Lancet 2000; 356: 18589,Optimal Nurse Need/Patient,Night Duty less than 2 turns/Week,护士数 = 床位数 x 7 + 4.3 10床ICU护士=74.3名 实际应配备护士数/床位：4:1,ICU理想的护士比例,Lancet 2000; 356: 18589, ICU类别 ICU数 床位数 医生数 护士数 医生/床位 护士/床位 内科 4 89 35 104 0.393：1 1.17：1 外科 9 104 72 234 0.692：1 2.25：1 综合 18 240 163 519 0.679：1 2.16：1 总和 31 433 270 857 0.624：1 1.98：1 ,中国ICU人力资源抽样调查,合格的人力资源匮乏,病人错误,患者相关的错误特点,1、对疾病的认识 2、不配合治疗 3、放弃治疗,Buetow. lancet, 2007;369:158-161,Am J Respir Crit Care Med 1998;157:1131,Unexpected Extubation,Patients contribution,N=177,放弃抢救 经济原因 错在家属,管理因素,管理者对错误的认识,Medicines tendency to view errors as failings that deserve blame Nurse training that emphasizes rules vs medicines emphasis on knowledge Corrective actions that focus on the individual vs the system.,个人态度,“no blood, no foul” Solving through individual power Disaster for their career,Patient Safety System,1. Medical error organization Analyzing the causes of errors System vs Individual Responsibility vs Knowledge,Patient Safety System,2. Reporting system Survey Mission Automatic reporting Close reporting,Error Reporting System Sharply Cuts ICU Mortality,Jan. 30, 2003 (San Antonio) Johns Hopkins University researchers have devised the first-ever error reporting system for the intensive care unit (ICU), which has the potential to cut mortality by as much as 30%,Obstacle: NASA vs Healthcares,Healthcares Perfect Keep secret Whose fault? Punishment,NASA Fallible Active reporting Whats happened? Promote safety,Tokarski C, Improve Patient Safety Summit 2001 From Medscape,Close Reporting,Healthcares Efforts are under way to develop,NASA 4-times Increase,1980-1995,Tokarski C, Improve Patient Safety Summit 2001 From Medscape,三、提高ICU安全性策略,1、管理流程,质量与安全管理小组,组成：医政机关、医师、护士 监测：医疗行为规范、错误发生情况 分析：错误发生的因素 改进：提出改进措施、方法 评估：分级评估与反馈,医疗流程,护理流程,监测流程,诊断 医嘱 操作 评估,规范医疗流程,诊断 医嘱 操作 评估,报警响应处理,系统功能变化,治疗反应评估,改善人力资源不足现状,合理的医护/床位比例 合理的人员结构配备,改善ICU环境,加强训练,No/1000Beds/year,Ways to improve,Daily