英国胸膜手术安全:每个人的房子都井然有序吗?英国防弹少年团国家胸膜服务组织审计和患者安全事件国家审查的反思。

IF 3.4 3区 医学 Q1 RESPIRATORY SYSTEM
Andrew Ewing Stanton, Mark Juniper, Eihab Bedawi, Laura McNaughton, Amelia O Clive, Duneesha De Fonseka, Avinash Aujayeb, Matthew Evison
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引用次数: 0

摘要

简介:2022年英国胸科学会胸膜服务组织审计强调了胸膜手术持续存在危害风险的证据。为了更好地了解这些安全问题的潜在原因,我们对来自国家报告和学习系统(NRLS)的患者安全事件进行了审查。方法:NRLS从2018年4月1日至2022年3月30日期间提交的任何3级、4级和5级事件中获取事件级患者安全数据,这些事件描述了胸膜干预造成的伤害,特别是胸腔引液插入或胸腔抽吸胸腔积液(液体)。结果:共发现256个事件。其中大多数与胸膜手术或其相关问题没有直接关系,因此被排除在外。最终,有21起事件(包括2起死亡事件)是相关的。17例涉及直接器官穿刺,以肝脏为主(n= 13)。11例涉及seldinger引流管,5例涉及钝性夹层引流管,1例涉及两者(未在4中详细说明)。只有4例明确详细说明了超声辅助入路的使用。在其余的病例中,超声波的使用在很大程度上根本不详细,或者使用的方法不清楚或不合适。大多数(19/21)事件发生在呼吸环境中。讨论:这些数据引起了人们对胸膜介入治疗液体的关注,在这些液体中,缺乏适当的超声使用可能导致了各种临床领域的发生。专业团体和学会应在国家一级强调这一点。我们欢迎即将进行的一项关于患者结局和死亡的国家机密调查研究,以帮助我们巩固对这种持续危害风险的潜在因素的理解,并使我们能够采取明确的行动来降低这种风险。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Pleural procedural safety in the UK: is everyone's house in order? Reflections from the BTS National Pleural Service Organisational Audit and a national review of patient safety incidents.

Introduction: The 2022 British Thoracic Society Pleural Services Organisational Audit highlighted evidence of ongoing risk of harm from pleural procedures. To better understand the underlying causes of these safety concerns we undertook a review of patient safety incidents from the National Reporting and Learning System (NRLS).

Methods: Incident-level patient safety data from NRLS were requested from any level 3, 4 and 5 incidents describing harm resulting from pleural intervention, specifically chest drain insertion or pleural aspiration for pleural effusions (fluid), submitted between 1 April 2018 and 30 March 2022.

Results: 256 incidents were identified. Most of these did not directly relate to a pleural procedure or its concerns and so were excluded. Ultimately, 21 incidents (including 2 deaths) were relevant. 17 involved direct organ puncture, predominantly liver (n= 13). 11 incidents involved seldinger drains, 5 blunt dissection drains and 1 involved both (not specified in 4). In only four incidents was it clearly detailed that an ultrasound-assisted approach had been used. In the remainder, the use of ultrasound was largely not detailed at all, or the approach used was not clear or inappropriate. Most (19/21) events occurred out with respiratory environments.

Discussion: These data raise concerns about pleural intervention for fluid occurring where lack of appropriate ultrasound use may have contributed in a variety of clinical areas. This should be highlighted at a national level by specialty groups and societies. We welcome an upcoming National Confidential Enquiry into Patient Outcome and Death study to help cement our understanding of factors underlying this ongoing risk of harm and to enable definitive action to be taken to reduce this risk.

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来源期刊
BMJ Open Respiratory Research
BMJ Open Respiratory Research RESPIRATORY SYSTEM-
CiteScore
6.60
自引率
2.40%
发文量
95
审稿时长
12 weeks
期刊介绍: BMJ Open Respiratory Research is a peer-reviewed, open access journal publishing respiratory and critical care medicine. It is the sister journal to Thorax and co-owned by the British Thoracic Society and BMJ. The journal focuses on robustness of methodology and scientific rigour with less emphasis on novelty or perceived impact. BMJ Open Respiratory Research operates a rapid review process, with continuous publication online, ensuring timely, up-to-date research is available worldwide. The journal publishes review articles and all research study types: Basic science including laboratory based experiments and animal models, Pilot studies or proof of concept, Observational studies, Study protocols, Registries, Clinical trials from phase I to multicentre randomised clinical trials, Systematic reviews and meta-analyses.
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