双程序核查预防骨科四肢手术患者错误及手术部位错误临床应用.doc

双程序核查预防骨科四肢手术患者错误及手术部位错误临床应用[摘要] 目的:探讨双程序核查在预防骨科四肢手术患者错误及手术部位错误的效果。方法:2006年3月~2009年8月,我院骨科共有择期骨科四肢手术患者1 322例,术前进行双程序核查。结果:核查出不合要求34例,所有患者按要求重新标记再核对无误后才能手术,程序执行以来未出现手术患者错误及手术部位错误等不良事件。结论:双程序核查患者资料能够为骨科四肢手术在防止手术患者错误及手术部位错误提供手术最大的安全性保障,杜绝因此而引起的法律诉讼,实施无需特殊条件,建议确立为制度并在临床推广使用。 [关键词] 双程序;骨科;四肢;预防;错误手术部位 [中图分类号] R473.6[文献标识码]C [文章编号]1673-7210(2010)05(c)-086-03 The dual-process examination in preventing wrong site surgery (WSS) in the limb orthopedics XIAO Qiaoxian (The People′s Hospital in Dongguan City, Guandong Province, Dongguan523018, China) [Abstract] Objective: To investigate the effect of the Dual-process examination in preventing Wrong site surgery (WSS) in the limb orthopedics. Methods: From March 2006 to August 2009, the Dual-process examination was carried out on 1 322 patients before limb orthopedic operation in schedule. Results: 34 cases were found out as non-conforming, then all patients were required re-marked and re-checked further before their limbs were operated. They could accept the operation before no mistake was verified. No incident of WSS had taken place, since the Dual-process examination was executed. Conclusion: The Dual-process examination could provide the maximum security for the limb orthopedic patient,eliminate the possibly involved litigation, need no special condition for the implementation, which could be established as a rule and used widely in clinic. [Key words] Dual-process examination; Orthopedics; Limb ; Prevention; Wrong site surgery 随着社会的发展,人们对医疗认知能力的逐渐提高,对医疗质量提出更高的要求,因医疗质量及医疗安全而引起的法律诉讼日渐增多。骨科四肢手术患者因左右对称,解剖部位相同而容易混淆,因错误手术患者及错误手术部位对患者来说是灾难性结果,为预防错误手术患者及错误手术部位的发生,总结2006年3月~2009年8月我院手术室根据相关资料[1-2]制订双程序核查患者身份资料及手术部位确认共1 322例,手术部位2 827个,没有出现手术患者错误及手术部位错误等不良事件,收到良好的效果,现报道如下: 1资料与方法 1.1一般资料 2006年3月~2009年8月,手术室共有择期骨科四肢手术患者共1 322例,其中,男1 012例,女310例,年龄5~106岁,平均52.6岁。其中,创伤患者908例,非创伤患者414例,手术部位既往有手术史患者320例,无手术史患者1 002例。单个解剖部位1 128例,2个解剖部位148例,3个解剖部位手术30例,4个以上解剖部位16例,手术部位总计2 827个。 1.2方法 1.2.1手术切口标记线的建立