Retrospective analysis of 240 surgery-related near misses_West China Medical Journal

Authors：

MO Hong ,  GONG Renrong , LAI Li , TU Xuehua

Department of Operating Room, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P. R. China;

Corresponding author：

GONG Renrong, Email: gongrenrong@163.com

Keywords：

Operation; Near miss; Characteristic; Reason

DOI：

10.7507/1002-0179.201612048

Video：

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Objective To summarize the characteristics of surgery-related near misses including events composition, cause of incident, specialty category, personnel allocation etc, and to provide experience of feedforward control for the nurses in operating room and a clinical basis of safety standards for the management of operating rooms. Method The 240 surgery-related near misses occurred between July 2014 and July 2016 were retrospectively analyzed, using frequencies and percentiles to describe the count data. Results The 240 surgery-related near misses were mainly associated with surgical stitches (91 cases, 37.9%), surgical dressings (52 cases, 21.7%) and surgical instruments (45 cases, 18.8%). The main features of the 91 cases of surgical stitching included loss of suture needles (40.7%, 37/91) and fracture events (37.4%, 34/91). Among the 52 cases of surgical dressings, the most commonly were gauze dressing events (43 cases, 82.7%), in which 19 were with unclear numbers of retained gauzes in the reoperation patient’s body, and 15 were postoperative counting anomalies. Among the 45 cases of surgical instruments, the fracture and defect were the most common (21 cases, 46.7%). Conclusion The operation nurses should focus on the prevention of suture needle loss, the surgical dressings loss and the fracture and defect of surgical instruments, etc, to reduce or avoid the surgery-related near misses.

Citation： MO Hong, GONG Renrong, LAI Li, TU Xuehua. Retrospective analysis of 240 surgery-related near misses. West China Medical Journal, 2017, 32(12): 1906-1909. doi: 10.7507/1002-0179.201612048 Copy

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1. 杨莘, 王祥, 邵文利, 等. 335 起护理不良事件分析及对策. 中华护理杂志, 2010, 45(2): 130-132.
2. Aspden P, Corrigan JM, Wolcott J, et al. Patient safety: achieving a new standard for care. Washington DC: National Academies Press, 2004.
3. Barach P, Small SD, Kaplan H, et al. Designing a confidential safety reporting system: in depth review of thirty major medical incident reporting systems, and near-miss safety reporting systems in the nuclear, aviation, and petrochemical industries. Anesthesiology, 1999, 91: A1209.
4. Rebbitt D. Pyramid power: a new view of the great safety pyramid. Prof Safety, 2014, 59(9): 30-34.
5. 石贞仙, 杜巧, 徐建萍, 等. 未遂事件上报激励机制在护理安全管理中的应用. 中国护理管理, 2011, 11(9): 53-56.
6. Hu CY, Raymond DJ. Lessons learned from hazardous chemical incidents-Louisiana Hazardous Substances Emergency Events Surveillance (HSEES) system. J Hazard Mater, 2004, 115(1/2/3): 33-38.
7. 万文洁, 孙晓, 施雁. 护理不良事件原因分析方法的研究现状. 中华护理杂志, 2012, 47(6): 565-567.
8. Tanaka K, Otsubo T, Tanaka M, et al. Similarity in predictors between near miss and adverse event among Japanese nurses working at teaching hospitals. Ind Health, 2010, 48(6): 775-782.
9. 周加玲, 王志成. 前馈控制在手术室护理安全管理中的应用. 重庆医学, 2010, 39(13): 1764-1766.
10. 中华护理杂志. 卫生部颁布《手术安全核查制度》. 中华护理杂志, 2010, 45 (10): 924.
11. Arriaga AF, Elbardissi AW, Regenbogen SE, et al. A policy-based intervention for the reduction of communication breakdowns in inpatient surgical care: results from a Harvard surgical safety collaborative. Ann Surg, 2011, 253(5): 849-854.

West China Medical Journal

Retrospective analysis of 240 surgery-related near misses

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