课件：加强手术管理确保病人安全.ppt

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,安全手术的10个事实,WHO正采取措施，通过以下途径解决这些问题: 急救和外科基本治疗全球行动； 创伤基本治疗指导原则； 第二届全球患者安全挑战行动。,全球实施手术：2.34亿例/年，外科治疗关系到数百万人的生命。 世界各地疾病类型发生的变化，对手术需求越来越多。 流行病和感染作为主要死亡原因正在让位于缺血性心脏病、 癌症和创伤，这些疾病都需要进行手术干预。 目前尚缺乏确保手术安全的国际规范，而证据表明: 如果遵守了某些 基本治疗标准，有一半以上手术相关并发症和死亡可以得到避免。 -Lancet 2008; 372: 13944,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估，每年至少有100万患者在手术过程中或手术后死亡。,事实 4,在全球范围内，关于外科治疗的信息只在个别研究中实现了标准化或进行了系统收集。 (世界各地大多数外科干预并没有记录) 在全球基础上衡量外科治疗， 对促进手术安全、预防疾病 和改进治疗至关重要。,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 。,事实 7,在过去30年中，麻醉实施已显著改进，但并非世界各地的情况都有改观。 在某些地区（撒哈拉沙漠以南非洲部分地区 ），与麻醉有关的死亡率仍高居不下，每150名接受全身麻醉的患者中就有1人死亡。,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%。,事实 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。,目标 1,确保正确的病人、正确的部位、正确的手术。,American Academy of Orth. Surgery. “AAOS Advisory Statement on Wrong-Site Surgery.“ Retrieved 25 Jan.2008, from /about/papers/advistmt/1015.asp. Australian Commission on Safety and Quality in Healthcare. “Ensuring Correct Patient, Correct Site, Correct Procedure.“ Retrieved 23 Aug.2007, from .au/internet/safety/publishing.nsf/content/former-pubs-archive-correct. Joint Commission. “A follow-up review of wrong site surgery.“ Retrieved 3 May, 2007, from /SentinelEvents/sentineleventalert/sea_24.htm. Joint Commission. “Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery.“ Retrieved 15 February, 2007, from /PatientSafety/UniversalProtocol/. Kwaan, M. R., D. M. Studdert, et al. (2006). “Incidence, patterns, and prevention of wrong-site surgery.“ Arch Surg 141(4): 353-7; discussion 357-8. National Patient Safety Agency. “Correct Site Surgery - Making your surgery safer.“ Retrieved 3 May, 2007, from http:/www.npsa.nhs.uk/site/media/documents/884_0186FEB05_01_26.pdf.,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。 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 mortality.“ 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 3,警惕并有效地准备，应对可能出现的威胁生命的气道阻碍或呼吸功能的丧失。,Murphy, M. and D. J. Doyle (2008). Airway evaluation. Management of the Difficult and Failed Airway. O. Hung and M. Murphy. New York, McGraw Hill: 3-15. Paix, A. D., J. A. Williamson, et al. (2005). “Crisis management during anaesthesia: difficult intubation.“ Qual Saf Health Care 14(3): e5. Shiga, T., Z. Wajima, et al. (2005). “Predicting difficult intubation in apparently normal patients: a meta-analysis of bedside screening test performance.“ Anesthesiology 103(2): 429-37.,目标 4,知晓并有效地准备，应对手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 Livingston. 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 among 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 administration 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: baseline 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. Grandbastien, 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 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., 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, 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 clinical 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. Lingard, 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 among 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.,目标 10,建立例行制度和程序， 监测手术的能力、数量和结果,Berwick, D. M. (2008). “The science of improvement.“ JAMA 299(10): 1182-4. Berwick, D. M., D. R. Calkins, et al. (2006). “The 100,000 lives campaign: setting a goal and a deadline for improving health care quality.“ JAMA 295(3): 324-7. Regenbogen, S. E., R. T. Lancaster, et al. (2008). “Does the Surgical Apgar Score measure intraoperative performance?“ Ann Surg 2008 Aug;248(2):320-8 Regenbogen SE, Ehrenfeld JM, Lipsitz SR, et al. Utility of the surgical apgar score: validation in 4119 patients. Arch Surg. 2009 Jan;144(1):30-6; discussion 37.,NEWS LETTER 2008-12,初步结果,发现： 术后并发症发生率