急危重癥搶救中的醫(yī)療風(fēng)險防范

急危重癥搶救地醫(yī)療風(fēng)險防范HealthcareRiskManagementIdentifyRisk

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GoodCatchesThinkBeyondtheObvioustoUncoverLatentFailuresDeployProvenAnalysisModelsforIncidentInvestigationInvestinaRobustRiskManagementInformationSystem(RMIS)FindtheRightBalanceofRiskFinancing/Transfer/Retention臨床病例女/三八歲既往史:一零年前因后背皮膚燒傷行植皮手術(shù)。六年前卵巢子宮內(nèi)膜異位囊腫剔除術(shù)。三年前診斷高血壓,自述BPmax一五零/九零mmHg,間斷頭暈,未予重視。一月前曾注射HPV疫苗(第二針）,注射后無明顯不適。主訴:胸悶,黑朦,發(fā)現(xiàn)低血壓一天現(xiàn)病史:一天前胸悶,外院就診HR一二零-一四零bpm,BPmax七零-八零/四零-五零,查ABGGLU二二.八mmol/L,cLac五.二mmol/L多巴胺升壓治療后BP可維持九零/六零mmHg,仍有胸悶,憋氣,大汗等不適凌晨就診急診監(jiān)測血壓最低至八七/六四mmHgNE泵入,HR一一二次/分,BP九一-一一三/七六-八七mmHgmmHg,RR二零次/分,SPO二九四%臨床病例收入MICU一五:三零入室后訴胸悶,伴大汗,四肢闕冷,NBP七零/六六mmHg@NE二四ug/min,HR一三八bpm將NE上調(diào)至六零ug/min,HR行上升至一五零bpm,BP七零+/四零+mmHg一五:三八在行橈動脈置管術(shù)過程患者出現(xiàn)呼之不應(yīng),HR突然下降至三二bpm,伴血壓下降,氧與下降,迅速心跳驟停即刻開始持續(xù)心外按壓氣管插管,機械通氣支持（VC模式,Vt四五零ml,PEEP五H二O,RR二零bpm,FiO二一零零%,可維持SpO二九三%-一零零%）。心電監(jiān)護間斷示室顫,室速,先后予非同步電除顫五次,并間斷靜推腎上腺素一mg×一五次,可達龍零.一五g×一次快速補液擴容一六:零零仍無自主心律恢復(fù)床旁超聲可見量心包積液床旁心包穿刺術(shù),引出血心包積液一零零ml后自主心律短期恢復(fù),但無法長期維持一七:二一患者自主心律恢復(fù)一七:五二急查血常規(guī)回報HGB明顯下降:一二五g/L→五八g/L,可見腹腔明顯膨隆,抽出暗紅色不凝血,考慮腹腔活動出血急危重癥-心肺復(fù)蘇(CPR)呼吸機有關(guān)肺炎地預(yù)防六HHypovolemiaHypoxiaHydrogenions(acidosis)HyperkalemiaorhypokalemiaHypothermiaHypoglycemia六TTabletsortoxinsCardiactamponadeTensionpneumothoraxThrombosis(myocardialinfarction)Thromboembolism(pulmonaryembolism)TraumaTakehomemessageChecklist可以有效防范部分醫(yī)療風(fēng)險,但是并不解決所有問題,甚至是主要問題ICU地醫(yī)療風(fēng)險=ICU地醫(yī)療差錯？Garrouste-OrgeasM,TimsitJF,VesinA,SchwebelC,etal:Selectedmedicalerrorsintheintensivecareunit:resultsoftheIATROREFstudy:partsIandII.AmJRespirCritCareMed二零一零;一八一(二):一三四-一四二Garrouste-OrgeasM,TimsitJF,VesinA,SchwebelC,etal:Selectedmedicalerrorsintheintensivecareunit:resultsoftheIATROREFstudy:partsIandII.AmJRespirCritCareMed二零一零;一八一(二):一三四-一四二ICU地醫(yī)療差錯Garrouste-OrgeasM,SoufirL,TabahA,SchwebelC,etal:Amultifacetedprogramforimprovingqualityofcareinintensivecareunits:IATROREFstudy.CritCareMed二零一二;四零(二):四六八-四七六Garrouste-OrgeasM,SoufirL,TabahA,SchwebelC,etal:Amultifacetedprogramforimprovingqualityofcareinintensivecareunits:IATROREFstudy.CritCareMed二零一二;四零(二):四六八-四七六霍桑效應(yīng)醫(yī)務(wù)員抑郁與耗竭對醫(yī)療差錯地影響Garrouste-OrgeasM,PerrinM,SoufirL,VesinA,etal:TheIatrorefstudy:medicalerrorsareassociatedwithsymptomsofdepressioninICUstaffbutnotburnoutorsafetyculture.IntensiveCareMed二零一五;四一(二):二七三-二八四醫(yī)務(wù)員抑郁與耗竭對醫(yī)療差錯地影響Garrouste-OrgeasM,PerrinM,SoufirL,VesinA,etal:TheIatrorefstudy:medicalerrorsareassociatedwithsymptomsofdepressioninICUstaffbutnotburnoutorsafetyculture.IntensiveCareMed二零一五;四一(二):二七三-二八四TakehomemessageChecklist可以有效防范部分醫(yī)療風(fēng)險,但是并不解決所有問題,甚至是主要問題醫(yī)療差錯部分是由于醫(yī)務(wù)員自身地狀態(tài)引起,需要改善工作條件急診收治患者二四小時內(nèi)非計劃轉(zhuǎn)入ICU地危險因素二零零七-二零零九所有急診數(shù)據(jù)納入一三家醫(yī)院,排除沒有過渡病房地醫(yī)院急診收治:內(nèi)科-外科病房/過渡病房DelgadoMK,LiuV,PinesJM,KipnisP,etal:Riskfactorsforunplannedtransfertointensivecarewithin二四hoursofadmissionfromtheemergencydepartmentinanintegratedhealthcaresystem.JHospMed二零一三;八(一):一三-一九急診收治患者二四小時內(nèi)非計劃轉(zhuǎn)入ICU地危險因素DelgadoMK,LiuV,PinesJM,KipnisP,etal:Riskfactorsforunplannedtransfertointensivecarewithin二四hoursofadmissionfromtheemergencydepartmentinanintegratedhealthcaresystem.JHospMed二零一三;八(一):一三-一九急診收治患者二四小時內(nèi)非計劃轉(zhuǎn)入ICU地危險因素DelgadoMK,LiuV,PinesJM,KipnisP,etal:Riskfactorsforunplannedtransfertointensivecarewithin二四hoursofadmissionfromtheemergencydepartmentinanintegratedhealthcaresystem.JHospMed二零一三;八(一):一三-一九急診收治患者二四小時內(nèi)非預(yù)期致命不良與錯誤ZhangE,HungSC,WuCH,ChenLL,etal:Adverseeventanderrorofunexpectedlife-threateningeventswithin二四hoursofEDadmission.AmJEmergMed二零一七;三五(三):四七九-四八三Diagnosticissues誤診Managementissues誤治Overlookedseverity忽視病情急診收治患者二四小時內(nèi)非預(yù)期致命不良與錯誤ZhangE,HungSC,WuCH,ChenLL,etal:Adverseeventanderrorofunexpectedlife-threateningeventswithin二四hoursofEDadmission.AmJEmergMed二零一七;三五(三):四七九-四八三社區(qū)獲得肺炎嚴重程度地評估SeminRespirCritCareMed二零一六;三七(零六):八八六-八九六呼吸頻率測量地準確LovettPB,BuchwaldJM,SturmannK,BijurP:Thevexatiousvital:neitherclinicalmeasurementsbynursesnoranelectronicmonitorprovidesaccuratemeasurementsofrespiratoryrateintriage.AnnEmergMed二零零五;四五(一):六八-七六生命體征記錄地缺失RedfernOC,GriffithsP,MaruottiA,RecioSaucedoA,etal:Theassociationbetweennursestaffinglevelsandthetimelinessofvitalsignsmonitoring:aretrospectiveobservationalstudyintheUK.BMJOpen二零一九;九(九):e零三二一五七病情地改變而非收治時地病情與ICU收治有關(guān)WangJ,HahnSS,KlineM,CohenRI:Earlyin-hospitalclinicaldeteriorationisnotpredictedbyseverityofillness,functionalstatus,ororbidity.IntJGenMed二零一七;一零:三二九-三三四六零零張床教學(xué)醫(yī)院紐約快速反應(yīng)小組(rapidresponseteam,RRT)TakehomemessageChecklist可以有效防范部分醫(yī)療風(fēng)險,但是并不解決所有問題,甚至是主要問題醫(yī)療差錯部分是由于醫(yī)務(wù)員自身地狀態(tài)引起,需要改善工作條件減少醫(yī)療風(fēng)險地關(guān)鍵準確地,及時地評估病情準確地診斷與鑒別診斷ICU診斷錯誤地發(fā)生率系統(tǒng)回顧三一篇遺體解剖研究五八六三例遺體解剖ClassI八%(三四三/四五一四)主要診斷錯誤,可能導(dǎo)致死亡ClassII一五%(六三七/四四零三)主要診斷錯誤,與死亡無直接關(guān)系ClassIII一五%(二六四/一七一一)次要診斷錯誤,與臨終疾病有關(guān)ClassIV二一%(一七五/八一六)其它次要診斷錯誤WintersB,CusterJ,GalvagnoSMJr,ColantuoniE,KapoorSG,LeeH,GoodeV,RobinsonK,NakhasiA,PronovostP,Newman-TokerD.Diagnosticerrorsintheintensivecareunit:asystematicreviewofautopsystudies.BMJQualSaf.二零一二Nov;二一(一一):八九四-九零二.

非計劃轉(zhuǎn)入ICU與不良地有關(guān)六家比利時急病醫(yī)院半年非計劃轉(zhuǎn)入ICU或RRT干預(yù)?存在可預(yù)防地不良MarquetK,ClaesN,DeTroyE,etal.Onefourthofunplannedtransferstoahigherlevelofcareareassociatedwithahighlypreventableadverseevent:apatientrecordreviewinsixBelgianhospitals.CritCareMed.二零一五May;四三(五):一零五三-六一.住院患者診斷錯誤地后果更為嚴重SaberTehraniAS,LeeH,MathewsSC,etal.二五-YearsummaryofUSmalpracticeclaimsfordiagnosticerrors一九八六-二零一零:ananalysisfromtheNationalPractitionerDataBank.BMJQualSaf.二零一三Aug;二二(八):六七二-八零.急危重癥診斷流程BerglPA,NanchalRS,SinghH:DiagnosticErrorintheCriticallyIII:DefiningtheProblemandExploringNextStepstoAdvanceIntensiveCareUnitSafety.AnnAmThoracSoc二零一八;一五(八):九零三-九零七急危重癥診斷流程障礙BerglPA,NanchalRS,SinghH:DiagnosticErrorintheCriticallyIII:DefiningtheProblemandExploringNextStepstoAdvanceIntensiveCareUnitSafety.AnnAmThoracSoc二零一八;一五(八):九零三-九零七赫拉克勒斯十二偉業(yè)IFEVER……SinghH.Editorial:helpinghealthcareorganizationstodefinediagnosticerrorsasmissedopportunitiesindiagnosis.JtmJQualPatientSaf二零一四;四零:九九–一零一.如何改善急危重癥地診斷水提高識別潛在錯誤地能力利用死亡或CPR等,對有關(guān)病例行充分討論常規(guī)開展同行評議,即便是沒有不良地病例提高團隊合作,以病為心開展診斷精簡,雙向溝通:ICU醫(yī)生/內(nèi)科/外科/放射科/病理科/微生物/檢驗科開放討論地多學(xué)科查房擴大家屬與醫(yī)生與多學(xué)科團隊地溝通改善接班,首診團隊持續(xù)參與診斷BerglPA,NanchalRS,SinghH:DiagnosticErrorintheCriticallyIII:DefiningtheProblemandExploringNextStepstoAdvanceIntensiveCareUnitSafety.AnnAmThoracSoc二零一八;一五(八):九零三-九零七如何改善急危重癥地診斷水加強診斷過程反饋多學(xué)科死亡討論,避免抱怨ICU與兄弟科室地雙向匯報診斷結(jié)果提高遺體解剖率擴大信息技術(shù)參與加強電子病歷系統(tǒng)遠程醫(yī)療BerglPA,NanchalRS,SinghH:DiagnosticErrorintheCriticallyIII:DefiningtheProblemandExploringNextStepstoAdvanceIntensiveCareUnitSafety.AnnAmThoracSoc二零一八;一五(八):九零三-九零七六HHypovolemiaHypoxiaHydrogenions(acidosis)HyperkalemiaorhypokalemiaHypothermiaHypoglycemia六TTabletsortoxinsCardiactamponadeTensionpneumothoraxThrombosis(myocardialinfarction)Thromboembolism(pulmonaryembolism)Trauma安德魯·湯瑪斯·威爾（AndrewThomasWeil,一九四二年七月八日－）是美兼用藥物治療與自然療法地醫(yī)生,教授及作家,同時也