一个被遗忘的输尿管支架案例

C. Otasowie, K. Chan
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引用次数: 0

摘要

外科医生、患者和相关医疗保健专业人员之间的适当协调对于防止输尿管支架留在原位等错误至关重要。这个案例突出了经典的“瑞士奶酪”模型,即错误导致所描述的后果。本案例讨论了对患者进行适当的支架前咨询(尽管在紧急情况下可能并不总是可行)的相关要点,强调放置支架的外科医生负责安排适当的支架管理计划,如果患者未能参加随访,则行政团队应通知患者,以及患者和外科医生之间确保管理计划被遵循的共同责任。不幸的是,没有广泛使用的全国性系统来记录和后续的支架置入随访。这通常依赖于外科医生自己预约/安排支架的随访(有时在管理团队的帮助下),和/或支架注册,如英国泌尿外科医生协会(BAUS)网站上描述的。然而,这些本地安排的系统也可能容易出现错误,如忘记或错误记录支架置入,给管理团队的电子邮件丢失或解释不正确,数据库损坏/错误/不可用,或患者离开该区域。对于遗忘支架的风险较高的患者,应特别注意。具体来说,那些对支架没有感觉的人,以及那些不完全了解没有得到适当随访的潜在并发症的人,比如这个病例。本文报告了X先生的病例,一位70岁的男性,由于输尿管支架广泛结痂而出现急性慢性肾衰竭,该支架被放置以减轻梗阻性尿病,随后被遗忘了近两年。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
One That Got Away: A Case of The Forgotten Ureteral Stent
Appropriate concordance between surgeon, patient and allied healthcare professionals is essential in preventing errors such as ureteric stents being left in situ. This case highlights the classic “Swiss cheese” model of errors leading to the described consequences. The case discusses pertinent points regarding appropriate pre-stent counselling of patients (although this may not always be feasible in the emergency setting), the emphasis on the surgeon who places a stent being responsible for arrange an appropriate management plan for the stent, the notification from the administrative team if a patient fails to attend follow up, as well as the joint responsibility between patient and surgeon to ensure the management plan is followed. Unfortunately, there is no widely used nationalised system in place for the recording and subsequent follow up of stent insertions. This usually either relies on the surgeon themselves to book / arrange follow up for the stent (sometimes with the help of the administrative team), and/or a stent registry such as the one described on the British Association of Urological Surgeons (BAUS) website. However, these locally arranged systems again may be prone to errors such as forgetting or incorrectly recording the stent insertion, emails to administrative teams being lost or not interpreted correctly, database corruption/errors/unavailability, or patients moving out of area. Special care should be taken with patients who may be at a higher risk of having a forgotten stent. Specifically, those who may have no sensation of a stent, and those who may not fully understand the potential complications of not being followed up appropriately such as in this case. This report presents the case of Mr X, a 70-year-old man who presented with acute-on-chronic renal failure due to an extensively encrusted ureteral stent that had been placed to alleviate obstructive uropathy, and subsequently forgotten for almost two years.
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