| BACKGROUNDIntravenous transfusion is one of the most common used clinical nursing skills.In 2009, China amounted to 10.4 billion infusion bottles of liquid, equivalent to 1.3 billion Chinese average infusion 8 bottles, much higher than the level of international 2.5-3.3. While infusing, local tissue necrosis following extravasations occurs frequently due to fluid volume excess, long-term intravenous infusion, the complexity of medication, inadvertent administration, et cetera.Under the Regulations on Handling Medical Malpractice, local injection causes tissue necrosis on more than 2% of adult BSA (body surface area) is defined to Grade IV medical malpractice. Malpractices of tissue necrosis often occurs due to transfusion extravasation, while high-risk vesicant medicine, such as cytotoxic agents, hyperosmolar agents, vasocompressive agents, electrolytes, strong acid,alkaline agents, is implemented with scalp needle or peripheral intravenous catheter,. Although some techniques that can be applied in case of extravasation, their efficacy is modest, while there is no real treatment per se. Surgical debridemen,skin grafting,or even amputation have to be taken if tissue damage is severe, which always lead to medical disputes.Transfusion extravasation can not be effectively reduced while preventive measures such as simply emphasis on nurses' responsibility,monitorâ…£sites at regular intervals,restricted movement of infusing limbs are implemented. There is a fact that nursing education only provides with basic training of infusion technology. Nevertheless, after they are engaged in nursing, further education which is supposed to be provided by hospitals on how to select type ofâ…£tools, site, high-pressure auxiliary equipments(infusion pumps,injector pumps), transfusion period base on the physicochemical properties of the drugs is still inadequate. As a result, problems from transfusion become one of the most common cases within nurse-patient disputes.PURPOSEBase on the analysis of the cross-sectional survey data of transfusion extravasation rate, the aim of the study is to use root-cause analysis to identify the factors that led to the problem of tissue necrosis, carry out comprehensive interventions, followed by changes in practice to prevent future episodes.SUBJECTS and METHOUDWith self-designed questionnaires, a cross-sectional survey of a random sample of inpatients in a certain Hospital was carried out to ascertain the rate of Intravenous transfusion extravasation. It also investigate those who suffer transfusion extravasation, including age, gender, cumulative days of transfusion, type ofâ…£device, with caregivers or not, whether predictability measures are taken, how long before the symptoms being discovered,site, area,grade et cetera. The grade of extravasation bases on the Infusion Nursing Standards of Practice published in 2006 by Infusion Nurses Society. All data were analyzed by SPSS 13.0 statistical software. Corrected data of age were for Likelihood-Ratio Chi-Square Test, the others were for frequency distribution,percentage and Chi-square test.The cases, involving transfusion exravasation from July 2009 to Nov 2010 of a certain hospital, were taken. The cases were graded as mild,moderate,severe,very severe according to severity of tissue damage. Severe and very severe tissue necrosis cases(14 cases) would apply a root cause analysis, and an interdisciplinary problem-solving team including a deputy director of Physicians,a head pharmacist,5 nurses were built to analysis. On the base of collecting data--both subjective and objective, event report including patient profiles, the physicochemical properties of the drugs,the type of puncture tools involved,site,infusion timing,when to find the symptoms, whether to use pressure accessorial equipments(eg, injection pumps, infusion pumps or high pressure syringes) was also required. Then a systematic analysis using Cause & Effect analysis (or Fishbone Analysis) was applied in order to identify process and system weaknesses, reach the direct cause, and find out the root cause, then differentiate problems and carry out precautious intervention.Under preceding root cause analysis, prevention programme included interventions with offering a printed education sheet, developing an extravasation prevention flow chart,to provide notes of high-risk extravasation drugs management, and formulate post-event efforts was performed.All nurses have to learn about this. Conducted a cross sectional survey of the accuracy rate of selecting puncture tools and site while hyperosmolar parenteral nutrition,cytotoxic agents are implemented among all inpatients at 16:00 in a randomly selected day before or after the intervention.Compared the cases with tissue necrosis happened due to hypertonia parenteral nutrition and cytotoxic agents extravasation subsequent to three months of intervention with the cases before intervention. The data of accuracy of selecting the/â…£device/puncture tools and puncture site before and after intervention in cytotoxic agents as well as hyperosmolar agents was analyzed by frequency distribution,percentage, Chi-square test. The cases with tissue necrosis were analyzed by frequency distribution.RESULTSThere are 1312 patients with transfusion in total 1861 patients at 16:00 at that day, infusion rates is 70.5%. A total of 32 extravasation events were reported in 30 patients.Proximate causes (also know as direct causes) are made up of several elements. Nurses'insufficient ability of evaluating the physicochemical properties of the drugs, incorrect puncture tools,puncture sites selection, high incidence rate during daytime and mid-night, more serious damage caused by pressure accessorial equipment, and nurses' lack of knowledge on transfusion extravasation all contribute to the problem.And the root cause goes to lack of guideline and education for nurses to prevent high-risk extravasation drugs from care management organizations.Before and after comparisons indicated significant increases in selecting proper puncture tools and sites while infusing cytotoxic agents and hyperosmolar agents. Its accurate rate reaches to 100% after intervention, while there are flaws before. The cases of tissue necrosis decreased from two to zero during the same period before and after nursing intervention.CONCLUSIONS1,choosing peripheral intravenous catheter are the main reason resulting in transfusion extravasation2,selecting improper puncture tools and sites,shortage of nursing manpower,using pressure accessorial equipment,insufficient walkround are the Proximate causes of transfusion extravasation from high risk medicine.3,lack of guideline and education for nurses to prevent high-risk extravasation drugs from care management organizations are the root causes 4,three-dimensional comprehensive nursing measures can effectively prevent tissue necrosis resulting from high-risk extravasation drugs... |
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