ICU质量控制——安全性策略（课件）

ICU质量控制 平安性策略,解放军总医院第二附属医院ICU,马朋林,提 纲,ICU 平安性现状,不平安因素分析,提高平安性对策,一、ICU 平安性现状,6,SIGMA,管理,PPM=3.4,百万次操作,错误发生,3.4次,ICU,质量评定,操作次数：,10003000,次,/,病人,/,天,观察、处理报警、监测、治疗,可预防错误：,36,个,/1000,病人,.,天,PPM=12-36,威胁病人生命错误：,占,13%,=4.7,个,/1000,病人,.,天。,Data from Jeffrey CCM 2005,ICU 百万分平安？,工业产品,=,生命？,ICU,质量控制目标,医疗错误相关死亡率,PPM=0,How Hazardous Is Health Care?,Lakshmi Halasyamani,MD,Michigan,“To Err Is Human,Errors caused Deaths,In US:44000-98000/Year,Kohn,Institute of Medicine 1999,In China:12900/year?,Adopted from CAC 1999,Errors Happened in ICU,Critical Care Safety Study,391 patients(1 year),1490 patient-days,277 errors,11%Life-threatening,Jeffrey M CCM 2005,Admitted,Refused,ICU与普通病房区别,Simchen E et al.Crit Care Med 2004;32:1654-1661,159 cases,二、不平安因素分析,ICU不平安因素,ICU环境因素,人力资源短缺,病人因素,管理因素,ICU环境,引起病人心理状态改变,Author,Cited from,Patient Type,Anxiety,Jones C,CCM 2001,ICU,33/45,(73%),Rotondi,CCM 2002,ICU,MV,100/150,(67%),Swaiss,MEJA 2004,ICU,MV,37/55,(68%),Sharon,AJCC 2004,31 ICUs,73/106,(69%),Leur,Crt Care 04,ICU,MV,66/123,(54%),Hsiao,AATW2006,ICU,MV,Serious,不仅只有病人紧张,Burnout in intensive care unit,Minerva Anesthesiol 2007 Apr;73(4):195-200,Am J Respir Crit Care Med.2007;175(7):698-704.,Intensive care med;2021 Jan;34(1):152-6,Burnout,contagion,among intensive care nurses,J Adv Nurs.2005 Aug;51(3):276-87.,是医疗错误的重要原因之一,HAP,普通病房：4,without MV,CRRT,IABP etc,2,With MV,without CRRT,IABP etc,3,With MV,and CRRT,IABP etc,Night Duty less than 2 turns/Week,护士数=床位数 x 7+4.3,10床ICU护士=74.3名,实际应配备护士数/床位：4:1,ICU,理想的护士比例,Lancet 2000;356:18589,ICU类别 ICU数 床位数 医生数 护士数 医生/床位 护士/床位,内科 4 89 35 104 0.393：1 1.17：1,外科 9 104 72 234 0.692：1 2.25：1,综合 18 240 163 519 0.679：1 2.16：1,总和 31 433 270 857 0.624：1 1.98：1,中国ICU人力资源抽样调查,合格的人力资源匮乏,医 师,护 士,错误人次 百分比,/总工作日 （%）,错误人次 百分比,/总工作日 （%）,总 数,76/1895 4.01,220/5351 4.11,学 历,大专以下,0/0 0,196/4741 4.13,本科,65/886 7.34,24/549 4.37,硕士以上,11/1009 1.1,0/61 0,职 称,初级,66/580 11.4,203/4343 4.67,中级,8/704 1.13,15/825 1.81,高级,2/611 0.32,2/183 1.09,工作时间,1年,18/153 11.8,146/1434 8.02,2-3年,53/793 6.68,28/1166 6.60,3年,5/949 0.53,46/2751 1.02,病人错误,患者相关的错误特点,1、对疾病的认识,2、不配合治疗,3、放弃治疗,Buetow.lancet,2007;369:158-161,Am J Respir Crit Care Med 1998;157:1131,Unexpected Extubation,Patients contribution,N=177,放弃抢救,经济原因,错在家属,管理因素,管理者对错误的认识,Medicines tendency to view errors as failings that deserve blame,Nurse training that emphasizes rules vs medicines emphasis on knowledge,Corrective actions that focus on the individual vs the system.,个人态度,“no blood,no foul,Solving through individual power,Disaster for their career,Patient Safety System,1.Medical error organization,Analyzing the causes of errors,System,vs,Individual,Responsibility,vs,Knowledge,Patient Safety System,2.Reporting system,Survey Mission,Automatic reporting,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(ICU),which has the potential to,cut mortality by as much as 30%,Obstacle:,NASA vs Healthcares,Healthcares,Perfect,Keep secret,Whose fault?,Punishment,NASA,Fallible,Active reporting,Whats happened?,Promote safety,Tokarski C,Improve Patient Safety Summit 2001,From Medscape,Close Reporting,Healthcares,Efforts are under way to develop,NASA,4-times Increase,1980-1995,Tokarski C,Improve Patient Safety Summit 2001,From Medscape,三、提高ICU平安性策略,1、管理流程,质量与平安管理小组,组成：医政机关、医师、护士,监测：医疗行为标准、错误发生情况,分析：错误发生的因素,改进：提出改进措施、方法,评估：分级评估与反响,医疗流程,护理流程,监测流程,诊断 医嘱 操作 评估,标准医疗流程,诊断 医嘱 操作 评估,报警响应处理,系统功能变化,治疗反响评估,改善人力资源缺乏现状,合理的医护/床位比例,合理的人员结构配备,改善ICU环境,Teaching Affiliation,No.of Hospitals,Medication Errors,Affect Outcomes,N-teach,203,3430 901,190 33,N-pharm-t,283,2620 305,120 27,Pharm-t,534,1990 248,70 22,Significance,p=0.0007,p=0.025,加强训练,No/1000Beds/year,Ways to improve,Daily round,Refresh Courses,Rule for specialty training,and qualification,Widely communication,总 结,ICU平安性问题应得到高度关注,ICU错误是多源因素的结果,提高平安性策略,提高对错误的认识,建立错误控制体系,制定并落实医疗行为标准,Thanks,