国际视角丨4例失败的抢救案例报告

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对临床恶化的识别和应对失败,是考核患者安全、医院绩效和护理质量的重要标准。虽然已有研究明确了患者、医院系统和人为因素在抢救失败的病案中的作用,但作为一个可能的影响因素,非注意盲视的作用被忽视了。

(图片来源于网络,图文无关)

在重症监护、急诊及围手术期情境下,非注意盲视与病情恶化患者的抢救失败:4例病案报告

Angela Jones,Megan-Jane Johnstone

摘  要

目的:在重症护理、急诊和围手术期护理情境下,探讨非注意盲视的特性和对患者安全的影响。

方法:从自然调研中选择了4例病案,分析护士如何识别和管理护理间隙(不连续性)。通过深入访谈采集数据,访谈的目标样本为71名护士,其中20名为重症护理护士,19名为急诊护士,16名为围手术期护士。以非注意盲视的角度,完成病案的鉴别、选择和分析。

结果:本文报告的4例病案提示,当患者的观测指标已提示临床恶化时,未能识别和处理,这可以用非注意盲视来解释。对本文报道的全部病案(1例除外),所有生命体征都进行了定期测量和记录。但是,医护团队未能“看到”临床恶化的早期征象。这些病案发生的临床环境极具压力和复杂性,伴随着高认知工作负荷、噪音和频繁干扰,为非注意盲视创造了条件。

结论:本报告涉及的病案提出了在危重医疗范围内,对抢救失败的病例来说,非注意盲视是一个突出的但被忽视的人为因素的可能性。进一步的学科交叉比较研究,可以确保更好地理解非注意盲视在重症监护情境下的特性及其对患者安全的可能的影响。

[关键词]  重症监护室;急诊科;卫生保健;抢救失败;人因工程;非注意盲视;护士;患者安全;围手术期

英文原文:

Inattentional blindness and failures to rescue the deteriorating patient in critical care, emergency and perioperative settings: four case scenarios / Angela Jones, Megan-Jane Johnstone // Deakin University, School of Nursing and Midwifery, Victoria, Australia ///

[Abstract]

Objective: To explore the nature and possible patient safety implications of inattentional blindness in critical care, emergency and perioperative nursing contexts. 

Methods: Analysis of four case scenarios drawn from a naturalistic inquiry investigating how nurses identify and manage gaps (discontinuities) in care. Data were collected via in-depth interviews from a purposeful sample of 71 nurses, of which 20 were critical care nurses, 19 were emergency nurses and 16 were perioperative nurses. Case scenarios were identified, selected and analysed using inattentional blindness as an interpretive frame. 

Results: The four case scenarios presented here suggest that failures to recognise and act upon patient observations suggestive of clinical deterioration could be explained by inattentional blindness. In all but one of the cases reported, vital signs were measured and recorded on a regular basis. However, teams of nurses and doctors failed to ‘see’ the early signs of clinical deterioration. The high-stress, high-complexity nature of the clinical settings in which these cases occurred coupled with high cognitive workload, noise and frequent interruptions create the conditions for inattentional blindness. 

Conclusion: The case scenarios considered in this report raise the possibility that inattentional blindness is a salient but overlooked human factor in failure to rescue events across the critical care spectrum. Further comparative cross-disciplinary research is warranted to enable a better understanding of the nature and possible patient safety implications of inattentional blindness in critical care nursing contexts.

[Keywords] 

critical care unit; emergency department; health care; failure to rescue; human factors engineering; inattentional blindness; nurses; patient safety; perioperative

作者单位:迪肯大学护理和助产学院

摘要出处:

http://dx.doi.org/10.1016/j.aucc.2016.09.005

Jones A, Johnstone MJ. Inattentional blindness and failures to rescue the deteriorating patient in critical care, emergency and perioperative settings: four case scenarios. Aust Crit Care,2017,30(4):219-223.

来源 :

《中国护理管理》2017年第7期。

为了让广大护理人员及时了解更多国际护理研究进展,增进我国与国际护理界学术交流,促进护理学科发展与临床实践水平的提升,《中国护理管理》于2017 年起开辟“国际视角”栏目,与澳大利亚知名期刊《Australian Critical Care》合作,每期刊登一篇精选原创论文的中英文摘要。该刊隶属于爱思唯尔集团,最新影响因子为1.907,五年影响因子为2.016。该刊经过严格的同行评审,接受世界各地的作者来稿,刊登重症护理相关的原创性研究、新技术和新方法、案例研究和述评等类型文章。

希望本栏目的信息能为广大护理同仁的科研和临床工作提供参考。




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