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| The occurrence of medical safety adverse events in acquired immune deficiency syndrome ward and preventive measures |
| HE Caiyu YAN Dingyan ZHU Yuzhu#br# |
| The Second Department of Infection, Xixi Hospital of Hangzhou, Zhejiang Province, Hangzhou 310023, China |
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Abstract Objective To study the occurrence of medical safety adverse events in acquired immune deficiency syndrome ward and preventive measures. Methods A total of 81 medical safety adverse events in acquired immune deficiency syndrome ward of Xixi Hospital of Hangzhou from January 2018 to April 2021 were retrospectively analyzed. The categories and severity of medical safety adverse events in acquired immune deficiency syndrome ward were analyzed, and the causes and preventive measures of adverse events were studied. Results Among 81 medical safety adverse events, 74 cases (91.36%) had adverse events of medical safety, and 7 medical staff (8.64%) had adverse events of occupational exposure. Among the adverse events, 27 cases (33.33%) had safety hazards, 25 cases (30.86%) had accidental extubation, 13 cases (16.05%) had pressure injury, and 9 cases (11.11%) had administration errors. Judging from the classification of event levels, there were 58 cases (38.75%) of grade Ⅳ events, 14 cases (55.00%) of grade Ⅲ events, and 9 cases (6.25%) of grade Ⅱ events. Among the 27 cases of safety hazards, 18 patients fell and 9 patients fell out of bed; 19 patients occurred during daytime and 8 patients occurred at night. Among the 25 cases of accidental extubation incidents, 20 patients occurred at night and 5 patients occurred during daytime; 16 patients occurred 1-3 days after catheterization, 7 patients occurred 4-7 days after catheterization, and 2 patients occurred 7 days after catheterization. Among the 13 cases of pressure injury, 10 patients were stage Ⅰ pressure injury and 3 patients were stage Ⅱ pressure injury; 10 patients were complicated by infectious pneumonia, and 3 patients were complicated by renal impairment. In the 9 cases of drug administration errors, the nurses did not check the number and type of drugs administered one by one in strict accordance with the drug administration process. Among the 7 cases of occupational exposure incidents, 5 cases were mucosal exposure and 2 cases were needle stick injuries; judging from the identity of the parties involved in the incident, the 7 parties were all in-hospital nurses; and they were all within three years of practice. Conclusion All kinds of medical safety adverse events are easy to occur in acquired immune deficiency syndrome ward. In clinical practice, more comprehensive nursing care and more strict quality control management should be adopted for patients in special wards to avoid all kinds of adverse events.
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