ICU質(zhì)量控制-安全性策略（課件）

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(duì)策一、ICU安全性現(xiàn)狀6SIGMA管理PPM=3.4百萬(wàn)次操作錯(cuò)誤發(fā)生3.4次ICU質(zhì)量評(píng)定操作次數(shù)：1000—3000次/病人/天

觀察、處理報(bào)警、監(jiān)測(cè)、治療可預(yù)防錯(cuò)誤：36個(gè)/1000病人.天

PPM=12-36威脅病人生命錯(cuò)誤：占13%=4.7個(gè)/1000病人.天。

DatafromJeffreyCCM2005ICU百萬(wàn)分安全？工業(yè)產(chǎn)品=生命？

ICU質(zhì)量控制目標(biāo)醫(yī)療錯(cuò)誤相關(guān)死亡率

PPM=0HowHazardousIsHealthCare?LakshmiHalasyamani,MD,Michigan“ToErrIsHuman”

ErrorscausedDeaths

InUS:44000-98000/Year

Kohn,InstituteofMedicine1999

InChina:12900/year???AdoptedfromCAC1999

ErrorsHappenedinICUCriticalCareSafetyStudy

391patients(1year)1490patient-days277errors

11%Life-threatening

JeffreyMCCM2005Admitted

RefusedICU與普通病房區(qū)別SimchenEetal.CritCareMed2004;32:1654-1661159cases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AuthorCitedfromPatientTypeAnxietyJonesCCCM2001ICU33/45(73%)RotondiCCM2002ICU,MV100/150(67%)SwaissMEJA2004ICU,MV37/55(68%)SharonAJCC200431ICUs73/106(69%)LeurCrtCare04ICU,MV66/123(54%)HsiaoAATW2006ICU,MVSerious不僅只有病人緊張BurnoutinintensivecareunitMinervaAnesthesiol2007Apr;73(4):195-200

AmJRespirCritCareMed.2007;175(7):698-704.Intensivecaremed;2008Jan;34(1):152-6BurnoutcontagionamongintensivecarenursesJAdvNurs.2005Aug;51(3):276-87.是醫(yī)療錯(cuò)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(cuò)誤發(fā)生的獨(dú)立高危因素MedicalerrorsinrelationtostaffworkhoursinICUNEJM,2004Ⅰ級(jí)人力要求Ⅱ級(jí)人力要求Ⅲ級(jí)人力要求Ⅳ級(jí)人力要求護(hù)士短缺百分率發(fā)生錯(cuò)誤病人百分率護(hù)士人力資源短缺與ICU錯(cuò)誤Hospitalmortalityinrelationtostaffworkload:a4-yearstudyinICULancet2000;356:185–89OptimalNurseNeed/Patient

Calculation0.5Stable,WithoutVasopressor,MV,CRRT,IABPetc1WithVasopressor,TJ-pumps>4,withoutMV,CRRT,IABPetc2WithMV,withoutCRRT,IABPetc3WithMV,andCRRT,IABPetcNightDutylessthan2turns/Week護(hù)士數(shù)=床位數(shù)x7+4.3

10床ICU護(hù)士=74.3名實(shí)際應(yīng)配備護(hù)士數(shù)/床位：4:1

ICU理想的護(hù)士比例Lancet2000;356:185–89━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━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489351040.393：11.17：1外科9104722340.692：12.25：1綜合182401635190.679：12.16：1────────────────────────────────

總和314332708570.624：11.98：1━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━

中國(guó)ICU人力資源抽樣調(diào)查合格的人力資源匱乏醫(yī)師護(hù)士錯(cuò)誤人次百分比/總工作日（%）錯(cuò)誤人次百分比/總工作日（%）總數(shù)76/18954.01220/53514.11學(xué)歷大專以下0/00196/47414.13本科65/8867.3424/5494.37碩士以上11/10091.10/610職稱初級(jí)66/58011.4203/43434.67中級(jí)8/7041.1315/8251.81高級(jí)2/6110.322/1831.09工作時(shí)間1年18/15311.8146/14348.022-3年53/7936.6828/11666.60>3年5/9490.5346/27511.02病人錯(cuò)誤患者相關(guān)的錯(cuò)誤特點(diǎn)

1、對(duì)疾病的認(rèn)識(shí)2、不配合治療3、放棄治療Buetow.lancet,2007;369:158-161AmJRespirCritCareMed1998;157:1131UnexpectedExtubationPatient’scontributionN=177放棄搶救經(jīng)濟(jì)原因錯(cuò)在家屬管理因素管理者對(duì)錯(cuò)誤的認(rèn)識(shí)Medicine'stendencytoviewerrorsasfailingsthatdeserveblameNursetrainingthatemphasizesrulesvsmedicine'semphasisonknowledgeCorrectiveactionsthatfocusontheindividualvsthesystem.個(gè)人態(tài)度“noblood,nofoul”SolvingthroughindividualpowerDisasterfortheircareerPatientSafetySystem1.Medicalerrororganization

AnalyzingthecausesoferrorsSystemvs

IndividualResponsibilityvs

Knowledge

PatientSafetySystem

2.Reportingsystem

SurveyMission

Automaticreporting

Closereporting

ErrorReportingSystemSharplyCutsICUMortality

Jan.30,2003(SanAntonio)—JohnsHopkinsUniversityresearchershavedevisedthefirst-evererrorreportingsystemfortheintensivecareunit(ICU),whichhasthepotentialtocutmortalitybyasmuchas30%Obstacle:

NASAvsHealthcaresHealthcaresPerfectKeepsecretWhosefault?Punishment

NASAFallibleActivereportingWhat’shappened?PromotesafetyTokarskiC,ImprovePatientSafetySummit2001FromMedscapeCloseReportingHealthcaresEffortsareunderwaytodevelop

NASA4-timesIncrease1980-1995TokarskiC,ImprovePatientSafetySummit2001FromMedscape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(jī)關(guān)、醫(yī)師、護(hù)士監(jiān)測(cè)：醫(yī)療行為規(guī)范、錯(cuò)誤發(fā)生情況分析：錯(cuò)誤發(fā)生的因素改進(jìn)：提出改進(jìn)措施、方法評(píng)估：分級(jí)評(píng)估與反饋醫(yī)療流程護(hù)理流程監(jiān)測(cè)流程診斷醫(yī)囑操作評(píng)估規(guī)范醫(yī)療流程診斷醫(yī)囑操作評(píng)估報(bào)警響應(yīng)處理系統(tǒng)功能變化治療反應(yīng)評(píng)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TeachingAffiliationNo.ofHospitalsMedicationErrorsAffectOutcomesN-teach2033430±901190±33N-pharm-t2832620±305120±27Pharm-t5341990±24870±22Significance