基于“瑞士奶酪模型”的监护仪安全风险管理
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摘要
目的:运用"瑞士奶酪模型"理论,设置防御层面降低监护仪安全风险。方法:针对"瑞士奶酪模型"理论中引发监护仪事故发生的科室设备管理、安全监管隐患、安全隐患先兆和安全操作措施4个层面,从设备管理员的岗位设置与风险管理标准化,设备巡检与定期培训和考核,定期预防性维护、质量控制及操作指导,监护仪使用和故障处理4个方面入手,采取相应措施进行监护仪安全风险管理。结果:管理实施后2017年第一季度监护仪使用故障率为2.67%,比安全风险管理前降低5.9%。结论:使用"瑞士奶酪模型"理论建立的监护仪安全风险防御系统,可降低监护仪使用风险,提升患者安全,有效预防和减少监护仪相关异常事件发生。
Objective: To set defensive layers for reducing the risks of monitor security by using the theory of "Swiss cheese model". Methods: In view of the four aspects of "Swiss cheese model" theory, which included equipment management for department, hidden danger of supervision for safety, omen of hidden danger of safety and measurement of safety operation that cause the occurrence of monitor accident, the corresponding measures were adopted to implement risk management for safety of monitor from 4 aspects included post setting of the equipment manager and standardization of risk management, routing inspection of equipment and regular training and assessment, regularly preventive maintenance, quality control and operation guidance, and using and fault handling of monitors. Results: After the management method was carried out, the failure rate of monitor was 2.67% in the first quarter of 2017, and it was reduced by 5.9% compared with that before it was carried out. Conclusion: The defensive system that is established by using "Swiss cheese model " theory for risk of monitor safety can reduce the operation risk of monitor, and improve safety for patient, and effectively prevent and reduce the occurrences of relevant abnormal events of monitor.
Objective: To set defensive layers for reducing the risks of monitor security by using the theory of "Swiss cheese model". Methods: In view of the four aspects of "Swiss cheese model" theory, which included equipment management for department, hidden danger of supervision for safety, omen of hidden danger of safety and measurement of safety operation that cause the occurrence of monitor accident, the corresponding measures were adopted to implement risk management for safety of monitor from 4 aspects included post setting of the equipment manager and standardization of risk management, routing inspection of equipment and regular training and assessment, regularly preventive maintenance, quality control and operation guidance, and using and fault handling of monitors. Results: After the management method was carried out, the failure rate of monitor was 2.67% in the first quarter of 2017, and it was reduced by 5.9% compared with that before it was carried out. Conclusion: The defensive system that is established by using "Swiss cheese model " theory for risk of monitor safety can reduce the operation risk of monitor, and improve safety for patient, and effectively prevent and reduce the occurrences of relevant abnormal events of monitor.
引文
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[2]陈宏文,崔飞易,廖伟光.“瑞士奶酪模型”在医疗设备使用风险管理中的应用[J].中国医疗设备,2016,31(5):130-132.
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[7]刘庆.多参数监护仪安全风险分析[J].中国医学装备,2016,13(10):29-32.
[8]郑娆.医院多参数监护仪开展质量控制及问题分析[J].中国医疗设备,2015,30(11):125-126.
[9]王守镜,徐林,王梦婷,等.多参数监护仪的质量控制分析[J].中国医疗设备,2013,28(10):62-63.
[10]李秋娟,崔骊,崔怡,等.多参数监护仪质量检测方法的分析研究[J].中国医学装备,2013,10(10):23-24.
[11]朱永丽,高关心,李庚,等.我院医疗器械风险管理探讨[J].中国医疗设备,2014,29(8):101-103.
[12]李晓梅,刘士龙,王建国,等.PM-9000多参数监护仪的预防性维护[J].中国医疗设备,2014,29(6):156-157.
[13]钱正瑛,金伟,杨俊.层次分析法在医疗设备风险评估中的应用研究[J].中国医疗设备,2015,30(9):59-62.
[14]井卫云.除颤监护仪的预防性维护[J].中国医疗设备,2015,30(6):169-170.
[15]朱海蛟.除颤仪临床使用的安全监测、分析、评估、预警及问题解决[J].辽宁医学杂志,2013,27(1):50-51.
[2]陈宏文,崔飞易,廖伟光.“瑞士奶酪模型”在医疗设备使用风险管理中的应用[J].中国医疗设备,2016,31(5):130-132.
[3]刘志勤.“瑞士奶酪模型”用于临床风险管控[J].医院院长论坛,2013(5):25-32.
[4]蔡贤黎,王萍,姚礼庆.基于瑞士奶酪模型的内镜中心病理标本管理[J].中国实用护理杂志,2015,31(z1):98-99.
[5]安梦娜,罗秦英,董卫华,等.“瑞士奶酪模型”用于静脉用药配置中心差错风险管控[J].中国药师,2016,19(12):2383-2385.
[6]李艳,谢晖,孙婷,等.Reason模型及其在医疗领域中的应用现状[J].解放军护理杂志,2016,33(11):29-32.
[7]刘庆.多参数监护仪安全风险分析[J].中国医学装备,2016,13(10):29-32.
[8]郑娆.医院多参数监护仪开展质量控制及问题分析[J].中国医疗设备,2015,30(11):125-126.
[9]王守镜,徐林,王梦婷,等.多参数监护仪的质量控制分析[J].中国医疗设备,2013,28(10):62-63.
[10]李秋娟,崔骊,崔怡,等.多参数监护仪质量检测方法的分析研究[J].中国医学装备,2013,10(10):23-24.
[11]朱永丽,高关心,李庚,等.我院医疗器械风险管理探讨[J].中国医疗设备,2014,29(8):101-103.
[12]李晓梅,刘士龙,王建国,等.PM-9000多参数监护仪的预防性维护[J].中国医疗设备,2014,29(6):156-157.
[13]钱正瑛,金伟,杨俊.层次分析法在医疗设备风险评估中的应用研究[J].中国医疗设备,2015,30(9):59-62.
[14]井卫云.除颤监护仪的预防性维护[J].中国医疗设备,2015,30(6):169-170.
[15]朱海蛟.除颤仪临床使用的安全监测、分析、评估、预警及问题解决[J].辽宁医学杂志,2013,27(1):50-51.