- 期刊
病人安全通報系統管路事件分析
Analysis on Tube Incidences from Patient Safety Reporting System
摘要
The objective of this study was to analyze inpatient tube incidences in a medical center in order to identify factors that may affect the outcomes of unplanned extubation. Conclusions generated from this study may provide caregivers valuable information in preventing tube incidences. We reviewed incident reports and medical charts of patients with tube incidents occurring from June 2004 to December 2006 in a medical center located in Taipei. Data on 94 tube incidents were collected, among which 61 patients experienced self-extubation. Demographics and other related information of the tube incidenceswere documented and analyzed. The densities of incidents are presented and compared within groups using independent t-test. It was found that high-risk patients were typically male, elderly, and from medical or intensive care units. Unplanned extubation often occurred with endotracheal-tube users, while patients were on bed rest, and under clear consciousness. Day or night shift was not a significant factor. Most of the tube incidents caused minor injuries. However, it was found that age, restraints, having a caregiver at the bedside, and activity type during the tube incidence were highly correlated with the occurrence of an unplanned extubation (p=0.05). We concluded that caregivers should appropriately assess weaning protocols to avoid unplanned extubation injury in order to reduce healthcare expenses and improve patient safety and healthcare quality.
並列摘要
The objective of this study was to analyze inpatient tube incidences in a medical center in order to identify factors that may affect the outcomes of unplanned extubation. Conclusions generated from this study may provide caregivers valuable information in preventing tube incidences. We reviewed incident reports and medical charts of patients with tube incidents occurring from June 2004 to December 2006 in a medical center located in Taipei. Data on 94 tube incidents were collected, among which 61 patients experienced self-extubation. Demographics and other related information of the tube incidenceswere documented and analyzed. The densities of incidents are presented and compared within groups using independent t-test. It was found that high-risk patients were typically male, elderly, and from medical or intensive care units. Unplanned extubation often occurred with endotracheal-tube users, while patients were on bed rest, and under clear consciousness. Day or night shift was not a significant factor. Most of the tube incidents caused minor injuries. However, it was found that age, restraints, having a caregiver at the bedside, and activity type during the tube incidence were highly correlated with the occurrence of an unplanned extubation (p=0.05). We concluded that caregivers should appropriately assess weaning protocols to avoid unplanned extubation injury in order to reduce healthcare expenses and improve patient safety and healthcare quality.