icu質(zhì)量控制安全性策略

1、ICU質(zhì)量控制 —安全性策略,解放軍總醫(yī)院第二附屬醫(yī)院ICU,馬朋林,提 綱,ICU 安全性現(xiàn)狀 不安全因素分析 提高安全性對策,一、ICU 安全性現(xiàn)狀,6 SIGMA 管理,PPM=3.4百萬次操作錯誤發(fā)生3.4次,ICU質(zhì)量評定,操作次數(shù)： 1000—3000次/病人/天 觀察、處理報警、監(jiān)測、治療可預(yù)防錯誤：36個/1000病人.天

2、 PPM=12-36威脅病人生命錯誤：占13% =4.7個/1000病人.天。 PPM=1.5-4.7,Data from Jeffrey CCM 2005,ICU 百萬分安全？,工業(yè)產(chǎn)品=生命？ ICU質(zhì)量控制目標(biāo) 醫(yī)療錯誤相關(guān)死亡率 PPM=0,How Hazardous Is Health Care?,Laksh

3、mi Halasyamani, MD, Michigan,“To Err Is Human”,Errors caused Deaths In US: 44000-98000 /Year Kohn, Institute of Medicine 1999 In China: 12900/year ??? Adopte

4、d from CAC 1999,Errors Happened in ICU,Critical Care Safety Study 391 patients (1 year) 1490 patient-days 277 errors 11% Life-threatenin

5、g Jeffrey M CCM 2005,Admitted,Refused,ICU與普通病房區(qū)別,Simchen E et al. Crit Care Med 2004; 32:1654-1661,,159 cases,二、不安全因素分析,ICU不安全因素,ICU環(huán)境因素人力資源短缺病人因素管理因素,ICU環(huán)境引起病人心理狀態(tài)改變,不僅只有病人緊張,Burnout in intens

6、ive care unitMinerva Anesthesiol 2007 Apr;73(4):195-200,Am J Respir Crit Care Med. 2007 ;175(7):698-704.,Intensive care med;2008 Jan;34(1):152-6,Burnout contagion among intensive care nursesJ Adv Nurs. 2005 Aug;51(3):2

7、76-87.,是醫(yī)療錯誤的重要原因之一,HAP 普通病房：<5% ICU: 15~20%,ICU環(huán)境增加院內(nèi)感染,人力資源短缺是醫(yī)療錯誤發(fā)生的獨立高危因素,Medical errors in relation to staff work hours in ICU,NEJM, 2004,,,護(hù)士人力資源短缺與ICU錯誤,Hospital mortality in relation to staf

8、f workload: a 4-year study in ICU,Lancet 2000; 356: 185–89,Optimal Nurse Need/Patient,Night Duty less than 2 turns/Week,護(hù)士數(shù) = 床位數(shù) x 7 + 4.3 10床ICU護(hù)士=74.3名實際應(yīng)配備護(hù)士數(shù)/床位：4:1,ICU理想的護(hù)士比例,Lancet 2000; 356:

9、 185–89,━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━ ICU類別 ICU數(shù) 床位數(shù) 醫(yī)生數(shù) 護(hù)士數(shù) 醫(yī)生/床位 護(hù)士/床位──────────────────────────────── 內(nèi)科 4 89 35 104 0.393：1 1.17：1 外科 9

10、 104 72 234 0.692：1 2.25：1 綜合 18 240 163 519 0.679：1 2.16：1──────────────────────────────── 總和 31 433 270 857

11、 0.624：1 1.98：1━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━,中國ICU人力資源抽樣調(diào)查,合格的人力資源匱乏,病人錯誤,患者相關(guān)的錯誤特點,1、對疾病的認(rèn)識2、不配合治療3、放棄治療,Buetow. lancet, 2007;369:158-161,Am J Respir Crit Care Med 1998;157:1131,Unexpected Extubation,P

12、atient’s contribution,N=177,放棄搶救 經(jīng)濟原因 錯在家屬,管理因素,管理者對錯誤的認(rèn)識,Medicine's tendency to view errors as failings that deserve blame Nurse training that emphasizes rules vs medicine's emph

13、asis on knowledge Corrective actions that focus on the individual vs the system.,個人態(tài)度,“no blood, no foul” Solving through individual power Disaster for their career,Patient Safety System,1. Medical error organi

14、zation Analyzing the causes of errorsSystem vs IndividualResponsibility vs Knowledge,Patient Safety System,2. Reporting system ? Survey Mission ? Automatic reporting

15、 ? Close reporting,Error Reporting System Sharply Cuts ICU Mortality,Jan. 30, 2003 (San Antonio) — Johns Hopkins University researchers have devised the first-ever error reporting system for the intensive care unit (IC

16、U), which has the potential to cut mortality by as much as 30%,Obstacle: NASA vs Healthcares,HealthcaresPerfectKeep secretWhose fault?Punishment,NASAFallibleActive reportingWhat’s happened? Promote safety

17、,Tokarski C, Improve Patient Safety Summit 2001 From Medscape,Close Reporting,HealthcaresEfforts are under way to develop,NASA4-times Increase,1980-1995,Tokarski C, Improve Patient Safety Summ

18、it 2001 From Medscape,三、提高ICU安全性策略,1、管理流程,,質(zhì)量與安全管理小組,組成：醫(yī)政機關(guān)、醫(yī)師、護(hù)士 監(jiān)測：醫(yī)療行為規(guī)范、錯誤發(fā)生情況分析：錯誤發(fā)生的因素改進(jìn)：提出改進(jìn)措施、方法評估：分級評估與反饋,醫(yī)療流程,護(hù)理流程,監(jiān)測流程,診斷 醫(yī)囑 操作 評估,,規(guī)范醫(yī)療流程,診斷 醫(yī)囑 操作 評估,報警響應(yīng)處理,,系統(tǒng)功能變化,

19、治療反應(yīng)評估,,,,,,改善人力資源不足現(xiàn)狀,合理的醫(yī)護(hù)/床位比例合理的人員結(jié)構(gòu)配備,改善ICU環(huán)境,加強訓(xùn)練,No/1000Beds/year,Ways to improve,Daily round Refresh Courses Rule for specialty training and qualification Widely communication,總 結(jié),ICU安全性問題應(yīng)得到高度關(guān)注 ICU