The analysis of risk factors and strategies of surgical items count near misses
10.3760/cma.j.cn211501-20220930-03042
- VernacularTitle:手术物品清点接近失误事件相关系统风险分析及对策
- Author:
Guangying LIU
1
;
Xiaohua AN
;
Wen XU
;
Liyun XIAO
;
Xin WANG
;
Jinbao MAO
Author Information
1. 山东第一医科大学附属省立医院东院麻醉手术科，济南 250021
- Keywords:
Risk factors;
Surgical items count;
Near-miss error;
Grey relational analysis;
Prevention and rectification
- From:
Chinese Journal of Practical Nursing
2023;39(20):1535-1542
- CountryChina
- Language:Chinese
-
Abstract:
Objective:To describe the characteristics and analyze risk factors for surgical items count near-miss errors stemming from the self-incident reports of staff nurses from operating room, to reduce the risk of counting surgical items and prevent the occurrence of the relative adverse events.Methods:This was a retrospective study. Used the self-made checklist to retrospect the surgical items count errors, relative characteristics and reasons from the operating room nurses of Department of Anesthesiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University reported from January 2017 to December 2021. Grey Relational Analysis was used to analyze and identify the risk elements.Results:A total of 98 surgical items count near-miss errors were reported by nurses.The unclear items were mainly classified into 6 categories, of which 52.04% (51/98) were disposable surgical items, 24.49% (24/98) were fine parts of surgical instruments, 14.28% (14/98) were implants, 5.10% (5/98) were electrosurgical instruments, 3.06% (3/98) were power systems, and 1.02% (1/98) were medical lasers; the disposable surgical items were the highest risk of surgical items count near-miss errors (non-standard behaviors of surgeons ξ 1=0.333); among the 9 risk factors, non-standard behaviors of surgeons ( r1 = 0.673), instrument nurses improper operation ( r4 = 0.691) and surgeons errors ( r2 = 0.693) were the most important influence factors. Conclusions:Analyzing the possible system risk factors resulting from the near-miss error could be a useful method for nurses to generate hierarchical risk-control strategies and improve surgical items count safety for patients. This com prerent the occurrence of adverse events.
