Research On Medical Adverse Events In A Tertiary Cancer Specialized Hospital In Shandong Province

BackgroundWith the development of social economy and the improvement of residents’ health awareness,hospitals and social residents pay more and more attention to medical safety,and medical safety has become one of the hot topics of social concern.Studies at home and abroad have shown that there are a considerable number of medical adverse events in daily hospital diagnosis and treatment activities,and these medical adverse events have brought huge losses to the health of patients and the operation of the medical system.In order to respond to adverse medical events and improve medical safety,the Chinese government has introduced a number of measures to encourage medical institutions and medical personnel to actively report adverse medical events,strengthen medical technology and improve medical safety through the analysis of adverse medical events.However,at present,the analysis and management of adverse medical events in China are still not perfect,and there are problems such as low data utilization,in-depth analysis of adverse events,and ignoring the differences between specialized hospitals and general hospitals.Therefore,it is of great significance to analyze the current situation and causes of hospital adverse medical events to reduce the incidence of hospital adverse medical events,improve the management and analysis ability of hospitals for adverse medical events,improve the medical safety of patients,and continuously improve the medical quality of hospitals.ObjectivesTo describe and analyze the medical adverse events reported by a tertiary cancer hospital in Shandong province in 2021,identify key medical adverse events that need to be key management and analysis by the hospital,and analyze the composition and main causes of key medical adverse events,and provide references and suggestions for cancer hospitals to reduce the occurrence and severity of medical adverse events,improve the medical safety of patients and continuously improve the quality of hospital care.Methods(1)This study used the text research method to read all of the data of medical adverse events reported by a tertiary cancer hospital in Shandong Province in 2021 one by one.All adverse event data were standardized,and qualitative data were quantitatively processed.Pareto rule was used to screen out key medical adverse events that need to be studied and analyzed by the hospital.The SHEL cause analysis model and fishbone diagram were used to identify the main causes of major medical adverse events and the main aspects requiring intervention and improvement by the hospital.(2)Chi-square test and Fisher exact probability method were used to identify the risk factors related to the severity of medical adverse events using SPSS23.0 statistical software.\The test level α=0.05.Results(1)Among the total 1538 medical adverse events,22.50%(346 cases)of the adverse events were grade Ⅳ safety hazard events without error,and 76.98%(1184 cases)of the events caused minor or serious harm to patients.92.33%(1420)of the events were patient-related medical adverse events.Nursing adverse events(429 cases,30.21%),drug adverse events(275 cases,19.37%),medical device adverse events(265 cases,18.66%)and diagnosis and treatment adverse events(154 cases,10.01%)were the four types of medical adverse events with the highest number of occurrences.The department of surgery(534 cases,34.72%),the department of Radiotherapy(404 cases,26.27%),the department of Internal medicine(275 cases,17.88%)and the department of gynecology(159 cases,10.34%)reported the most number and proportion of adverse medical events.(2)Five kinds of adverse events,including falling/falling out of bed and unplanned extubation in nursing adverse events,adverse drug reaction events in drug adverse events,adverse device events and adverse treatment events,are the key medical adverse events that are harmful to patients,occur in large numbers,and need to be focused on.(3)The analysis results of fishbone diagram and SHEL model showed that the main causes of falls/falling out of bed were the patient’s own physical weakness and other physiological reasons,behavioral reasons such as persistent action,the accompanying reasons such as neglect/neglect of accompanying,the medical staffs lack of risk assessment of patients,and insufficient supervision/inspection of patients.(4)In unplanned extubation events.The results of fishbone diagram and SHEL model analysis showed that the main causes of unplanned extubation events were physiological reasons such as patients’ unconsciousness,behavioral reasons such as dressing and undressing/self-removal,accompanying reasons such as negligence/lack of attention to patients,medical staffs failure to carry out risk assessment on patients,inadequate supervision/inspection of patients and unsutured catheter/fixation.(5)In adverse drug reaction events.The analysis results of fishbone diagram and SHEL model showed that patients’ own allergic constitution and drugs’ own toxic and side effects were the main causes of ADR events.(6)Among adverse device events.The results of fishbone diagram and SHEL model analysis showed that the defects/aging/failure of equipment and improper use/lack of maintenance of equipment by medical personnel were the main causes of adverse device events.(7)Among the medical adverse events.The analysis results of fishbone diagram and SHEL model showed that the main causes of adverse events in diagnosis and treatment were patients’own disease/physical poor,inadequate examination and evaluation of patients by medical staff,inadequate supervision of patients,unreasonable diagnosis and treatment plan of medical staff,and inadequate operation of surgical examination.(8)The analysis results of fishbone diagram and SHEL cause analysis model showed that for the 994 cases of major medical adverse events in the above five categories,the patients were weak and persisted in acting against the doctor’s advice,the toxic and side effects of drugs themselves,the defects/damage of facilities and equipment themselves,and the medical staff did not carry out risk assessment/insufficient assessment of patients.Inadequate supervision/inspection of patients and inadequate nursing/operation are the main causes of adverse medical events.The human factor(L),the hardware factor(H)and the technical level and operation standard of the medical personnel(S)in the hospital are the main factors that need the hospital to pay attention to and improve.Conclusion and recommendationsThe results show that medical adverse events are harmful,large in number,wide in type and widely involved in hospitals.At the same time,affected by the differences in patients’diseases,there are great differences between oncology hospitals and general hospitals in the occurrence of medical adverse events in departments and drug types.The analysis results of fishbone diagram and SHEL cause analysis model show that patients and companions are important factors that need to be paid attention to by hospitals,and the clinical experience and technical level of medical staff are crucial to ensure medical safety.Meanwhile,hospitals need to pay more attention to and maintain public places such as outdoor squares and various facilities in hospitals.Based on the above conclusions,this study makes the following recommendations:(1)Strengthen the management of key departments and key drugs.(2)Strengthen supervision and inspection of key populations and facilities.(3)Improve the technical and professional literacy of medical personnel and optimize the allocation of human resources.(4)Using scientific quality management means to promote the continuous improvement and enhancement of medical quality.(5)Strengthen the construction of hospital safety culture to prevent the occurrence of adverse medical events.