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find Keyword "不良事件" 58 results
  • 不同年资护士对不良事件上报态度的调查研究

    目的探讨不同年资护士对不良事件的上报态度。 方法在2014年10月-2015年1月利用临床不良事件报告研究量表,随机对某三级甲等医院不同年资护士进行集中调查,评价不同年资(新入职组、低年资组、中年资组、高年资组)护士对不良事件的上报态度,采用单因素方差分析进行统计分析。 结果共发放370份问卷,收回有效问卷355份,问卷有效回收率为95.9%。新入职组79人,低年资组121人,中年资组88人,高年资组67人。不同年资护士对不良事件上报态度差异无统计学意义(F=1.465,P=0.224)。 结论加强护士安全意识及不良事件相关知识的培训,建立非惩罚性的工作环境,倡导人文关怀,培养正确的不良事件上报态度,提升护士对不良事件的上报意愿,有利于护理服务质量不断提升。

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  • Effectiveness and safety of multi-artery graft strategy for coronary bypass with small incision in the left chest for 64 patients

    ObjectiveTo investigate the safety and effectiveness of the multi-artery graf tstrategy for coronary bypass (MICS-CABG) with small incision in the left chest, and to provide experience for the promotion of this technique.MethodsThe clinical data of 64 patients with MICS-CABG in Department of Cardiac Surgery of Peking University Third Hospital from December 2015 to November 2019 were retrospectively analyzed. There were 54 males and 10 females, aged 36-77 (61.1±8.7) years. The left lateral thoracic incision (5-8 cm) was made through the 5th intercostal incision, and the operation was performed under off-pump CABG. With the help of the chest wall suspension device and the heart fixator, the proximal anastomosis of the ascending aorta, anastomosis of the target vessels of the  left anterior descending (LAD), left circumflex (LCX) and right coronary artery (RCA) systems were completed. The number of grafts was 2-4 (2.3±0.5) including 2 grafts in 45 patients, 3 grafts in 17 patients and 4 grafts in 2 patients. Three patients were treated with percutaneous intervention (PCI) hybridization and 62 patients were treated with total artery bypass graft. Coronary angiography was performed within 7 days after the operation to evaluate the graft patency rate. The incidence of major adverse cardiac and cerebrovascular events (MACCE) was recorded in the follow-up. The MACCE rate was calculated by Kaplan-Meier method.ResultsNone of the patients was transferred to thoracotomy and no intra-aortic balloon counterpulsation (IABP) or extracorporeal membrane oxygenation (ECMO) was used during the operation. Incision infection was in 1 patient and reoperation in 2 patients (all were postoperative hemorrhage). Within 30 days after surgery, MACCE occurred in 1 patient, including 1 patient of non-fatal myocardial infarction. The overall patency rate of angiography bypass was 96.2%, and the patency rate of anterior descending branch bypass was 98.2%. Follow-up was performed from 12 to 60 months (median follow-up time was 28 months). The loss rate was 7.8% (5/64). The incidence of MACCE was 84.9% (95%CI 79.5%-90.3%).ConclusionThe MICS-CABG can achieve completed re-vascularization and totally artery-CABG and the short-term and medium-term clinical results of the operation are good.

    Release date:2021-03-05 06:30 Export PDF Favorites Scan
  • 案例分析法在低年资护士培训中的实践与体会

    目的 探讨应用案例分析法进行教育培训,对提高低年资护士安全意识的影响及效果。 方法 2009年-2011年期间连续3年对低年资护士分别采用案例回放、现身说法、课堂讨论等方法进行护理安全培训。 结果 实施培训后,低年资护士的安全意识明显提高(P<0.05),护理不良事件发生率逐年下降,各级质量检查部门的满意度提高,特别是患者对护理工作的满意度提高,形成护理安全教育内部培训资料长期保存。 结论 案例分析法培训能提高低年资护士的安全意识,是护理安全教育的一种新尝试及较好的在职培训方法。

    Release date:2016-09-08 09:16 Export PDF Favorites Scan
  • 手术室日间护理查房对手术不良事件的控制观察

    目的 观察手术室日间护理查房后对手术不良事件的控制效果。 方法 选择实行日间护理查房前后的择期手术患者各750例,以2012年6月-2013年12月(实施日间护理查房前)作为对照组,以2014年8月-2015年11月(实施日间护理查房后)作为观察组,统计记录两组手术中不良事件的发生情况,对比分析手术室日间护理查房的效果。 结果 观察组不良事件的发生率为0.27%,对照组不良事件发生率为1.20%,两组不良事件发生率比较差异有统计学意义(P<0.05)。 结论 手术室日间护理查房后对控制手术不良事件有明显效果,提高了手术的安全度,值得临床推广。

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  • 人为因素输血差错的瑞士奶酪模型分析

    目的采用瑞士奶酪模型对1例输血差错事件中的人为因素进行分析,为管理者降低此类事件发生率提供参考。 方法根据2013年3月输血中发生的1例人为因素造成的差错事件,采用瑞士奶酪模型对事故因素从组织管理、不安全监督、护理人员不安全行为的前兆及不安全行为等方面进行分析。 结果该输血差错事件的人为因素涉及瑞士奶酪模型中的各方面。 结论应用瑞士奶酪模型可全面对护理不良事件中人为因素进行分析,丰富护理管理者处理不良事件的思维方式,有利于降低其发生率,值得借鉴。

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  • Risk factors for perfusionist-related near-miss event: A retrospective cohort study in a single center

    ObjectiveTo explore the risk factors and countermeasures of the perfusionist-related near-miss event (NME) in cardiopulmonary bypass (CPB). MethodsThe clinical data of the patients who underwent cardiac surgery in the Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University from March 2020 to July 2021 were retrospectively analyzed. According to whether NME occurred during the operation, the patients were divided into an NME group and a non-NME group. The clinical data of the two groups were compared, and the risk factors for NME were analyzed. ResultsA total of 702 patients were enrolled, including 424 males and 278 females with a median age of 56.0 years. There were 125 patients in the NME group and 577 patients in the non-NME group. The occurrence rate of NME was 17.81%. Univariate analysis showed that there were statistical differences between the two groups in the gender, body surface area, CPB time, European system for cardiac operative risk evaluation score, emergency surgery, type of surgery, night CPB initiation, modified ultrafiltration use, multi-device control, average operation time, et al. (all P<0.05). The above variables were dimensionality reduction processed by least absolute shrinkage and selection operator regression, and the λ of minimum mean square error of 10-fold cross validation was 0.014. The variables of the corresponding model were selected as follows: multi-device control, night CPB initiation, minimum hematocrit, modified ultrafiltration use, CPB time. The results of multivariate logistic regression showed that night CPB initiation [OR=9.658, 95%CI (4.735. 19.701), P<0.01] and CPB time [OR=1.003, 95%CI (1.001, 1.006), P=0.014] were independent risk factors for NME. ConclusionNight CPB initiation and CPB time are independent risk factors for NME during CPB, which should be recognized and early warned in clinical work.

    Release date:2024-04-28 03:40 Export PDF Favorites Scan
  • 曲妥珠单抗生物类似药与原研曲妥珠单抗联合帕妥珠单抗治疗HER2阳性乳腺癌患者疗效与安全性的回顾性队列研究

    目的比较HER2阳性乳腺癌患者在新辅助治疗中原研曲妥珠单抗与生物类似药的病理完全缓解(pathologic complete response,pCR)率及不良事件发生率的差异。方法采用回顾性分析法,收集 2021年1月至2022年10月期间在西南医科大学附属医院乳腺外科完成TCbHP方案新辅助治疗及手术治疗的 117例人类表皮生长因子受体2(human epidermal growth factor receptor 2,HER2) 阳性乳腺癌患者的临床病理资料。疗效评价依据实体肿瘤疗效评价标准(RECIST)1.1和 Miller-Payne(MP)系统,采用不良事件通用术语标准5.0进行不良事件发生率统计。结果117例患者中达到总体病理完全缓解(total pathologic complete response,tpCR)者曲妥珠单抗生物类似药汉曲优(HLX02,Zercepac)组占比70.2% (33/47),原研曲妥珠单抗赫赛汀组占比72.9% (51/70),2组比较差异无统计学意义(P=0.755);达到乳腺病理完全缓解(breast pathologic complete response,bpCR)者汉曲优组占比76.6% (36/47),赫赛汀组占比74.3.9% (52/70),2组比较差异无统计学意义(P=0.777)。分子分型为HER2+HR+ (三阳性)组与HER2+HR–(HER2过表达)组患者的tpCR率比较差异有统计学意义(61.6%比88.6%,P=0.002),bpCR率比较差异也有统计学意义(67.1%比88.6%,P=0.009)。在HER2+HR+患者中汉曲优组与赫赛汀组的tpCR率比较差异无统计学意义(66.7%比57.5%,P=0.423),bpCR率比较差异也无统计学意义(75.8%比60.0%,P=0.154);在HER2+HR–患者中汉曲优组与赫赛汀组的的tpCR率比较差异无统计学意义(78.6%比93.3%,P=0.354),bpCR率比较差异也无统计学意义(78.6%比93.3%,P=0.354)。治疗后所有患者均出现了可控的不良事件, 2组患者在心脏、血液系统和肝肾功能方面的不良事件发生率以及 ≥3 级不良事件的发生率均相似,差异均无统计学意义(P>0.05)。结论赫赛汀与其生物类似药汉曲优在新辅助治疗中的疗效和安全性相似,这为 HER2 阳性乳腺癌患者提供了更多的治疗选择。

    Release date:2024-04-25 01:50 Export PDF Favorites Scan
  • Research of learning curves for unilateral biportal endoscopy technique and associated postoperative adverse events

    ObjectiveTo summarize the characteristics of the learning curve and the occurrence of postoperative adverse events during the development of unilateral biportal endoscopy (UBE) technique by comparing the clinical data of early and late patients treated with UBE technique. Methods All patients who underwent single-level UBE technique between April 1, 2020 and December 31, 2021 were selected as the research subjects. According to the surgical options, all patients were allocated into 3 groups: unilateral decompression and discectomy (UDD) group, unilateral laminotomy for bilateral decompression (ULBD) group, and lumbar intervertebral fusion (LIF) group. The first 60 cases from each group were extracted and ranked orderly. The endoscopic operation time, the times of fluoroscopy during non-internal fixation implantation, the postoperative hospital stay, the drainage volume, the decrease of hemoglobin, the decrease of hematocrit, and the adverse events were collected. In each group, the patients were allocated into early and late cases according to the operation sequence. The first 30 cases of each group were classified as early cases, and the last 30 cases as late cases. Statistical analysis was performed on the above observation indicators between the early and late cases, and a scatter plot of relevant data changes was drawn to observe the change trend. Results Compared with the early cases, the endoscopic operation time and the times of fluoroscopy during non-internal fixation implantation of late cases in each group were significantly lower (P<0.05); the postoperative hospital stay of late cases in LIF group was significantly shorter (P<0.05); the decreased values of hemoglobin and hematokrit of late cases in ULBD group and LIF group were significantly lower (P<0.05); the postoperative drainage volume of late cases in ULBD group significantly decreased (P<0.05). The endoscopic operation time and the times of fluoroscopy during non-internal fixation implantation of 3 groups showed a significant downward trend. The adverse events occurred in 3 early cases and 1 late case of the UDD group, in 6 and 3 cases of the UBLD group, and 8 and 3 cases of the LIF group, respectively. The difference was not significant between the early and late cases (P>0.05). Conclusion In the early practice of UBE technique, there is a high incidence of complication, and the surgical trauma is relatively large, which is related to the lack of understanding of the UBE technique characteristics and insufficient surgical experience. With the proficiency of surgical techniques and accumulation of experience, the operation time and the incidence of postoperative adverse events were significantly reduced.

    Release date:2022-11-02 10:05 Export PDF Favorites Scan
  • The interpretation of 2019 ASGE guideline on the role of endoscopy for bleeding from chronic radiation proctopathy

    Radiation proctopathy, which can be categorized as acute and chronic, is defined as the radiation damage to the rectum caused by radiation therapy in patients with pelvic malignancies. Chronic radiation proctopathy can cause complications such as rectal bleeding, which severely affects patients’ quality of life. At present, endoscopic therapy has become the primary method for diagnosis and treatment of bleeding from chronic radiation proctopathy. In October 2019, the American Society for Gastrointestinal Endoscopy (ASGE) published "ASGE guideline on the role of endoscopy for bleeding from chronic radiation". The guideline described the effectiveness and safety of different endoscopic therapies such as argon plasma coagulation, bipolar electrocoagulation, heater probe, radiofrequency ablation, cryoablation, etc. in the treatment of bleeding from chronic radiation. This paper interprets it to provide references for clinicians in the treatment of bleeding from chronic radiation.

    Release date:2020-08-19 01:33 Export PDF Favorites Scan
  • Core techniques and adverse events in anterior cruciate ligament reconstruction using a new generation of artificial ligaments: the consensus of Chinese specialists based on a modified Delphi method (Part 2)

    Objective Anterior cruciate ligament (ACL) reconstruction using a new generation of artificial ligaments (NGAL) gained popularity in China owing to its good effectiveness and early functional recovery, but iatrogenic surgical failures and preconceived misconceptions have seriously affected its standardized clinical application. A specialist consensus is now developed to provide guidance and reference for orthopaedic sports medicine doctors when adopting or considering the NGAL for ACL reconstruction. Methods The consensus on the core techniques and adverse events in ACL reconstruction using the NGAL was developed by a modified Delphi method, referring exclusively to the NGAL for ACL reconstruction approved by the National Medical Products Administration (NMPA). Consensus specialists were selected from the members of the Chinese Association of Orthopaedic Surgeons (CAOS) and the Chinese Society of Sports Medicine (CSSM). The drafting team summarized the draft consensus terms based on medical evidence and organized rounds of investigation: two rounds of online questionnaire investigation and the final round of face-to-face meeting. After discussion, revision, and voting, a consensus on the draft consensus term was reached when the agreement rate exceeded 85%. The consensus terms were categorized as “strong” (agreement rate: 95.0%-100%), “moderate” (agreement rate: 90.0%-94.9%), and “basic” (agreement rate: 85.0%-89.9%). ResultsThirty-one specialists completed the questionnaire investigation. They all practiced in university teaching hospitals (Grade-A tertiary hospitals) from 16 provinces, autonomous regions, and municipalities in China. Among them, 28 were chief physicians and 3 were associate chief physicians; 22 were professors and 7 were associate professors; the average seniority in orthopedic sports medicine was 25.2 years (range, 12-40 years); the average seniority in performing ACL reconstruction procedures was 13.2 years (range, 7-23 years); in terms of the number of ACL reconstruction using the NGAL, 18 completed more than 100 cases, of which 6 had more than 300 cases; in terms of research, 28 had published more than 1 related paper in the past 5 years, of which 13 had published more than 3 related papers. Twenty-six specialists attended the face-to-face meeting and reached a consensus on 9 terms, including 8 strong terms and 1 moderate term. Conclusion ACL reconstruction using the NGAL must deploy “isometric” or “near-isometric” reconstruction and should preserve the natural ACL remnants as much as possible. Bone tunnel positioning can be performed using intraoperative radiographic measurements or the lateral femoral intercondylar ridge as reference marks. Incorrect positioning of the bone tunnel is the main reason of surgical failure, and there is a lack of consensus on handling interference screws during revision. Bone tunnel enlargement exists after reconstruction but rarely causes related symptoms. Synovitis and infection are uncommon complications. The aging effect of polyethylene terephthalate fiber on the long-term clinical outcomes is unknown and deserves attention.

    Release date:2022-09-30 09:59 Export PDF Favorites Scan
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