摘要目的 评价危警事件报告系统对临床麻醉质量的影响.方法 采取自愿、匿名、免责、保密的方式对围手术期发生且与麻醉相关的危警事件进行自行上报,于2012年9月至2016年8月由科室专人定期收集、分类、建档、风险评估后进行回顾性分析,对危警事件进行分类,统计4年度报告率;采用严重性与概率分析对危警事件进行风险评估;分析引起危警事件的诱发风险因素.结果 4年度危警事件报告率为0.551％.第1年度至第4年度,报告率依次为0.729％、0.598％、0.819％和0.368％,伤害事件发生率依次为0.112％、0.106％、0.133％和0.031％.第1年度和第2年度危警事件报告率、伤害事件发生率及报告率呈降低趋势,第3年度上升,第4年度降低(P＜0.05).危警事件类型构成比前3位分别为设备使用相关事件、呼吸系统相关事件和工作流程相关事件.患者损伤事件属于极高风险事件;麻醉科医护人员因素为危警事件的首位诱发风险因素.结论 危警事件报告系统可发现和纠正麻醉科存在的系统性风险及其诱发因素,是持续提高临床麻醉服务质量的有效方法.

abstractsObjective To evaluate the effect of Critical Incident Reporting System on the quality of clinical anesthesia.Methods Anesthesia-related critical incidents happened in the perioperative period were reported in voluntary,anonymous,no punishment and confidential manners.The data was collected,classified and documented by assigned professionals on a regular basis from September 2012 to August 2016.The critical incidents were retrospectively analyzed after the risk was assessed.The 4-year reporting rate was collected.The risk of critical incidents was assessed using severity and probability analysis,and the critical incidents-inducing risk factors were analyzed.Results The 4-year reporting rate of critical incidents was 0.551％.From 1st to 4th year,the reporting rates were 0.729％,0.598％,0.819％ and 0.368％,respectively,and the incidence of injury incidents was 0.112％,0.106％,0.133％ and 0.031％,respectively.The reporting rate of critical incidents and incidence and reporting rate of the injury incidents showed a decreasing trend for 1st and 2nd year,significantly increased for 3rd year and decreased for 4th year (P＜0.05).The first three critical incident categories were equipment use and respiratory system-and workflowrelated incidents.Patient injury during surgery was considered an extremely high risk incident;the factor of the medical staff in the department of anesthesiology is the first critical incidents-inducing risk factor.Conclusion Critical Incident Reporting System can discover and correct the system-related risk and the inducing factors in the department of anesthesiology and is an effective method of improving the service quality of clinical anesthesia.