3 インシデントレポートからみた手術室のリスクマネージメント(当院における医療安全管理の現況,第586回新潟医学会)

概要

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Incident reports submitted in the operating room of Niigata University Hospital were analyzed to clarify the incidence, nature, and the cause of non-injurious errors and adverse events. From April 2001 to November 2002, 211 reports were submitted, and nurses submitted 92% of all reports. The nature of the events was classified into 10 categories. The level was graded into 0 to 5 according to the seriousness of the events. Over the level 3 was regarded as adverse event or the negligence. The event related the violation of the basic rules was the most popular about the nature, followed by the events related direct injury, misplacement of operating tools, and misadministration of drugs. The population of the level 0 to 5 was 16.6, 31.8, 36.0, 11.4, 0, and 0.9%, respectively. No adverse error occurred in the events related identification of the individual patient and operation site. The causes consisted of the breach of the double-check system, lack of the basic knowledge of resident anesthesiologists, misinputting of the data of the patients, too many manuals and checklists, and violation of the rules. Want of medical engineer was also a major problem.
新潟大学の論文
2003-12-10