Retrospective Analysis And Risk Prevention Of 1585 Cases Of Adverse Medical Events In A Tertiary Hospital In Shenzhen

Objective:A retrospective analysis of 1585 cases of medical safety adverse events in a tertiary hospital,Identify risk factors and propose improvement measures,to reduce the occurrence of adverse medical events,Develop risk prevention strategies,To provide decision-making basis for ensuring patient safety and continuous improvement of medical quality.Methods:a retrospective analysis,adverse events in a hospital were summarized and sorted out,and the top four events with the highest incidence were screened out for retrospective analysis.It mainly includes types of adverse events,severity index classification,risk factors leading to errors,links of error occurrence,occurrence rules,consequences,root cause analysis and improvement measures.Spss17.0 was used for data entry and statistical analysis,and percentage was used for descriptive analysis of general materials.Using the rank sum test,,c~2test,Fisher’s exact probability analysis of the relevant factors leading to injury,the relationship between related factors and the outcome of the injury,the test level a=0.05.Result:(1)The top four in the incidence rate is the medication error event,fall event,Pressure sore care event,Unplanned extubation,accounted for 57.8%(1133 cases),14.4%(282 cases),4.9%(97 cases)and 3.7%(73 cases)of all adverse events(2)Inpatients were the main group with medication errors accounting for 74.6%(845 cases);ME mainly occurs in the second level,accounting for 79.0%(896 cases);ME mainly occurred in prescriptions and transmissions,accounting for 77.1%(874cases);Followed by the administration and monitoring links accounted for 13.3%(151 cases);The type of ME was unreasonable with the drug regimen,the wrong dosage,the wrong route,the wrong frequency,the wrong drug was opened,and the drug error was the most important,accounting for 23.04%,23.04%,12.97%,7.77%,6.79%,6.88%;Physicians are the main cause of medication errors 70.9%(804 cases),The medication error was mainly reported by the pharmacist 73.8%(836 cases),Medical staff lacks knowledge of drugs,fails to follow the operating procedures/does not perform double check,distraction,and lack of risk awareness is the main cause of medication errors;(3)The surgical system is 63.8%(180 cases)of high-risk departments with falls;The fall mainly occurred during night shifts,accounting for 64.6%(182 cases);In the ward area,the bedside and the restroom were the high incidence sites of falls,accounting for 31.2%(88 cases),22.3%(63 cases),and 20.9%(59 cases);The damage result is based on level 0 no damage and level 1 mild damage.The degree of falling bed injury was correlated with the patient’s body mass index(BMI),the visiting department,the accompanying situation,and the location of the occurrence,and the difference was statistically significant(p<0.05);Age,time of day,location,situational status,and whether or not the accompanying staff were related to the cause of the fall,the difference was statistically significant(p<0.05).Patient physiological and behavioral factors,item facilities factors,and lack of patient compliance were the main factors leading to injury,accounting for 43.9%(124 cases),14.2%(40 cases),and 12.1%(34 cases).(4)Elderly patients aged 65 years and older are high-risk groups of pressure ulcers,accounting for 48.5%(47 cases);Braden pressure ulcer risk assessment results suggest that 86.6%of patients have a risk of pressure ulcers;The oncology department and ICU are high-risk departments for pressure ulcers,accounting for28.9%(28 cases)and 20.6%(20 cases);The top three patients with pressure ulcers were diagnosed with tumor disease in the order of 28.9%(28 cases),respiratory diseases 15.5%(15 cases),and nervous system diseases 14.4%(14 cases);The stage was 37.1%(36 cases)in stage II,27.8%(27 cases)in stage I,and 26.8%(26 cases)in undefined stage;The results of root cause analysis indicated that the risk factors related to pressure sores were mainly 92.8%(90 cases),80.4%(78 cases)in long-term bed rest,80.4%(78 cases)in forced position limitation,and 77.3%(75cases)high nutritional score;The site of pressure sore is concentrated in the appendix,heel,nose.(5)Elderly patients over the age of 65,ICU and oncology patients are the main groups of unplanned extubation,the proportion was 52.1%(38 cases)and 50.7%(37cases);Unplanned extubation mainly occurred in the nighttime period,accounting for78%;the extraction method was mainly self-extracting,accounting for 61.6%(45cases);the main type of drainage tube was 47.9%(35 cases);Unplanned extubation events accounted for 79.5%of the SI=O events(58 cases);There was a significant correlation between the use of sedative drugs and the degree of unplanned extubation(P<0.05);94.5%of extubation events are related to the patient’s physiological and behavioral factors,which is the primary factor leading to unplanned extubation;Conclusion:(1)physician prescription is the source and root of medication errors,and clinical pharmacists are the key to ensure the safety and rational medication of patients.(2)Elderly patients over 65 years old,ICU and tumor department,Night shift are the common risk factor for adverse events,Key nursing and monitoring should be carried out for the above groups and time periods.(3)There was a significant correlation between the degree of fall injury and the body mass index(BMI)of the patient,the visiting department,the accompanying care,and the place of occurrence(P<0.05),it is suggested that health care workers should take preventive and nursing measures according to risk factors.(4)It is an important way to take targeted preventive measures for high-risk groups,high-risk departments,frequent time and place,and vulnerable situations according to the law of occurrence of adverse events.(5)the results of root cause analysis show that adverse events are not caused by a single factor,suggesting that hospital managers should take comprehensive measures to prevent medical risks from improving and optimizing the work process,strengthening personnel skill training,improving the quality of medical care,and strengthening patient safety education.(6)Establish a good reporting system for adverse events,analyze the adverse events that have occurred,it is helpful to find the problems in the work flow and system,and is of great significance to improve the quality of medical service.