Hastanelerde bildirimi yapılan istenmeyen olayların değerlendirilmesi: Bir eğitim ve araştırma hastanesi örneği
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2024
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Open Access Color
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Sağlıkta kalite çalışmalarının temelinde hastanelerdeki istenmeyen olayların önüne geçerek hem hasta hem çalışan açısından güvenli bir sistem inşa etme çabası bulunmaktadır. Bu amaç doğrultusunda geliştirilen standartlar, süreç tanımlamaları ve kontrol basamakları ile hastanelerdeki istenmeyen olayların önüne geçilmeye çalışılmaktadır. Tüm çabalara rağmen engellenemeyen istenmeyen olayların kayıt altına alınması, bu olayların nedenlerinin analiz edilmesi ve elde edilen bulgulara göre karar vericilerin sistemi iyileştirmeleri beklenmektedir. Bu tez çalışmasında hastanelerdeki ramak kala ve gerçekleşen istenmeyen olayların bildirim sistemine yansımalarını ve istenmeyen olayların kök nedenlerinin değerlendirilmesi sonucunda karar alıcılara istenmeyen olayların en aza indirilebilmesi için öneriler sunulması amaçlanmıştır. Çalışmada; İstanbul'da hizmet veren bir eğitim ve araştırma hastanesinde son beş yılda (Ocak 2018- Aralık 2022 yılları arasında) istenmeyen olay bildirim sistemine bildirimi yapılan toplam 2304 içerisinden; tıbbi süreçler ile ilgili olan 1524 istenmeyen olay bildirim kaydı incelenmiş, olayların çeşitli değişkenlere göre boylamsal analizleri yapılarak detaylı bulgular elde edilmiştir. Analizler sonucunda; bildirilen istenmeyen olayların önemli bir bölümünün (%76,5) hasta güvenliği ile ilgili olduğu görülmüştür. Hasta güvenliği kapsamında en sık düşme olaylarının (%35,5), çalışan güvenliğinde ise en sık kesici delici alet yaralanmalarının (%11,0) bildirildiği tespit edilmiştir. İstenmeyen olaylar en çok (%24,8) dahili kliniklerde meydana gelmekteyken, sisteme en fazla (%25) bildirim yapan biriminde yine dahili kliniklerdir. İstenmeyen olaylar en çok (%36,5) hemşire/ebelerin dahil olduğu süreçlerde yaşanmıştır. Çalışan kaynaklı meydana gelen istenmeyen olayların (%67,8) büyük çoğunluğunun ((%61,3) tanımlanmış prosedür ve kurallara uygun işlem yapılmadığından yaşanmış olduğu görülmüştür. Sonuç olarak hem hasta güvenliğini artırmak hem de çalışanların güvenliğini sağlamak için belirgin riskler hakkında (düşmeler, kesici delici alet yaralanmaları vb.) eğitim programları düzenlenmelidir. Bu eğitimler, risklerin nasıl azaltılacağına dair bilgi, becerileri ve farkındalığı artırabilir.
The basis of quality studies in health is the effort to build a safe system for both patients and providers by preventing unwanted incidents in hospitals. With the standards, process definitions and control steps developed for this purpose, unwanted incidents in hospitals are tried to be prevented. It is expected that unwanted events that cannot be prevented despite all efforts will be recorded, the causes of these events will be analyzed and decision makers will improve the system according to the findings obtained. In this thesis study, it is aimed to evaluate the reflections of near-miss and actual unintended events in hospitals on the notification system and the root causes of unintended events and to provide recommendations to decision makers to minimize unintended events. In the study, 1524 adverse event notification records related to medical processes were examined among a total of 2304 adverse event notification records reported to the adverse event notification system in the last five years (between January 2018 and December 2022) in a training and research hospital serving in Istanbul, and detailed findings were obtained by longitudinal analysis of the events according to various variables. As a result of the analysis, it was observed that a significant portion (76.5%) of the reported adverse events were related to patient safety. Within the scope of patient safety, falls were reported most frequently (35.5%), while sharps injuries were reported most frequently (11.0%) in provider safety. Unwanted events occurred most frequently (24.8%) in internal clinics, while the unit that reported the most (25%) to the system was also internal clinics. Most (36.5%) untoward incidents occurred in processes involving nurses/midwives. It was observed that the majority (67.8%) of the untoward incidents (61.3%) that occurred due to providers were due to not performing procedures in accordance with the defined procedures and rules. As a result, training programs on significant risks (falls, sharps injuries, etc.) should be organized both to increase patient safety and to ensure the safety of providers. These trainings can increase knowledge, skills and awareness on how to reduce risks.
The basis of quality studies in health is the effort to build a safe system for both patients and providers by preventing unwanted incidents in hospitals. With the standards, process definitions and control steps developed for this purpose, unwanted incidents in hospitals are tried to be prevented. It is expected that unwanted events that cannot be prevented despite all efforts will be recorded, the causes of these events will be analyzed and decision makers will improve the system according to the findings obtained. In this thesis study, it is aimed to evaluate the reflections of near-miss and actual unintended events in hospitals on the notification system and the root causes of unintended events and to provide recommendations to decision makers to minimize unintended events. In the study, 1524 adverse event notification records related to medical processes were examined among a total of 2304 adverse event notification records reported to the adverse event notification system in the last five years (between January 2018 and December 2022) in a training and research hospital serving in Istanbul, and detailed findings were obtained by longitudinal analysis of the events according to various variables. As a result of the analysis, it was observed that a significant portion (76.5%) of the reported adverse events were related to patient safety. Within the scope of patient safety, falls were reported most frequently (35.5%), while sharps injuries were reported most frequently (11.0%) in provider safety. Unwanted events occurred most frequently (24.8%) in internal clinics, while the unit that reported the most (25%) to the system was also internal clinics. Most (36.5%) untoward incidents occurred in processes involving nurses/midwives. It was observed that the majority (67.8%) of the untoward incidents (61.3%) that occurred due to providers were due to not performing procedures in accordance with the defined procedures and rules. As a result, training programs on significant risks (falls, sharps injuries, etc.) should be organized both to increase patient safety and to ensure the safety of providers. These trainings can increase knowledge, skills and awareness on how to reduce risks.
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Sağlık Kurumları Yönetimi, Health Care Management
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96