SHEL模式在急诊静脉用药护理安全管理中的应用

目的探讨SHEL模式在急诊静脉用药护理安全管理中的应用效果,确保患者用药安全。方法应用SHEL模式对以往发生的用药护理差错的相关因素进行分析,然后有针对性制订加强安全用药护理管理措施,包括提高护理人员的业务素质,改造工作环境和工作流程,加强管理及时消除安全隐患等。结果SHEL模式实施后用药护理差错发生率显著降低,护士安全用药知识得分中总分及三查七对的内容和方法等4个条目得分显著提高,护士安全用药行为合格率显著提高（P〈0．05．P〈0．01）。结论应用SHEL模式分析与护士用药有关的差错事故发生原因,制订有针对性的安全用药护理管理措施,可完善护士与用药相关的知识结构,规范护士安全用药行为,降低差错发生率,从而提高护理质量。     

SHEL模式在临床护理教学安全管理中的应用

目的探讨SHEL模式在临床护理教学安全管理中的应用效果.方法应用SHEL模式,对实习护生发生的护理差错进行相关因素分析,针对性地制订加强护理安全管理措施,并对889名实习护生进行临床护理教学安全管理,分别于实习前后采用自行设计的实习护生护理安全问卷调查表进行调查.结果实习后护生的安全意识较实习前显著增强(均P＜0.01),消除护理不安全隐患42起,杜绝护理差错9起,发生护理小差错1起.结论应用SHEL模式进行临床护理教学,可减少或避免护理差错事故的发生,保证患者生命安全,提高临床护理教学质量.     

配偶夫妻疾病沟通与肠造口患者感知社会约束的交叉滞后模型

目的 探讨SHEL事故分析法在院前急救护理安全管理中的应用效果.方法 应用SHEL事故分析法对2010年1月至2011年12月院前急救护理工作中出现的25例次护理缺陷进行分析,制定护理安全管理措施并进行针对性的管理.结果 加强护理安全管理后,2012年1～12月发生护理缺陷4例次,较管理前(25例次)显著减少(P＜0.05).结论 应用SHEL事故分析法对院前急救护理缺陷进行原因分析,针对性的制定护理安全管理措施,能明显降低护理缺陷的发生,保证护理安全.     

Patients′participation in safety control program:effect appraisal

目的 探讨住院患者参与安全目标管理的可行性.方法 对病区护士加强相关患者安全目标知识培训,明确患者参与安全目标管理的内涵,组织患者交流参与管理的经验,以预防护理差错事故发生.结果 95％以上的住院患者能主动参与医疗护理安全管理,护理不良事件发生率较参与管理前显著降低(P＜0.01).结论 患者参与安全目标管理,可提高惠者参与安全目标管理的积极性,减少护理不良事件发生,有助于提高患者医疗护理安全,提高医疗护理质量.     

破窗理论在临床用药护理安全管理中的应用

目的 探讨破窗理论在临床用药护理安全管理中的应用及效果.方法 组建临床用药管理小组,对用药过程及管理中的盲点即"破窗"进行讨论、学习,对存在的共性问题定期进行集体操作练习.结果 实施后用药差错发生率显著低于实施前(P＜0.01),患者投诉率降低,医生满意率提高,但与实施前比较,差异无显著性意义(均P＞0.05).结论 应用破窗理论指导临床用药护理安全管理,提高了护理人员对药品安全的认知度,明确了药品使用的规范性、准确性和科学性,实现了临床用药安全.     

头脑风暴法在护理安全管理中的应用

目的 提高护理人员安全防范意识,有效预防护理差错事故发生.方法 护理部和病区采用头脑风暴法定期召开护理安全讨论会,即护理人员针对某一护理安全问题,结合临床工作实际,畅所欲言地发表自己的观点,提出安全隐患,制订整改措施并实施.结果 实施头脑风暴法后护理差错缺陷登记上报率显著上升(P＜0.01),而实际发生数下降,护理人员参与安全讨论的时间及发言人数显著增加(均P＜0.01),护理人员对待安全讨论的满意度从84.87%提高到98.16%(P＜0.01).结论 将头脑风暴法引入护理安全管理中,有利于提高护理人员安全意识,规范其护理行为,保障护理安全,有效降低护理差错事故发生,提高护理质量.     

Patient participation in medication safety management: prevention of drug administration errors

目的 探讨患者参与用药安全管理的方法.方法 在“患者参与患者安全”理念的指导下,成立给药安全管理小组,开展护士安全教育,改进健康教育流程,改进查对流程增加患者参与给药前查对的步骤.结果 实施患者参与安全用药管理后,给药差错发生率显著低于实施前(P＜0.01).结论 患者参与安全用药管理可有效预防和降低给药差错.     

基于危险预知训练模式的护理不良事件风险管理成效

目的 探讨危险预知训练模式在护理不良事件风险管理中的应用效果。方法 采取前瞻性类实验研究设计，2022年1-6月收治患者13 346例纳入干预前组，2022年7-12月收治患者11 520例纳入干预后组。干预前组采用常规护理不良事件管理方法，干预后组采用基于危险预知训练模式的护理不良事件风险管理。比较干预前后护士安全行为得分，以及2组患者不良事件、投诉纠纷发生率。结果 干预后护士安全行为得分较干预前显著提高(P<0.05);干预后组患者用药错误、跌倒、非计划性拔管类不良事件、投诉纠纷发生率显著低于干预前组(均P<0.05)。结论 基于危险预知训练模式的护理不良事件风险管理能够有效提高护士的安全行为，降低不良事件、投诉纠纷的发生率。     

SHEL模式在手术室护士锐器伤防范中的应用

目的 探讨SHEL模式在防范手术室护士锐器伤中的应用价值.方法 依据SHEL模式制订手术室护士锐器伤防范措施,比较实施前、后手术护士锐器伤发生率.结果 实施前锐器伤发生率为10.5%.实施后为4.2%.实施前后比较,差异有统计学意义(P<0.01).结论 实施SHEL模式能有效防范手术护士锐器伤的发生.     

Survey on execution of verbal medical order for emergency rescue and countermeasure

目的 加强口头医嘱管理,减少口头医嘱执行差错率.方法 自制问卷调查3所医院口头医嘱执行状况,针对问题采取规范口头医嘱使用范围,对医生、护士分别制定口头医嘱细则等.结果 采取管理措施后,用药错误、用药剂量错误、用药方法错误、漏执行医嘱、延误执行医嘱发生率显著减少( P＜0.05,P＜0.01).结论 针对性的制度建设与管理有利于提高口头医嘱执行水平.     

Vasopressor hormone response following mesenteric traction during major abdominal surgery

Background : We investigated the vasopressor hormone response following mesenteric traction (MT) with hypotension due to prostacyclin (PGI₂) release in patients undergoing abdominal surgery with a combined general and epidural anesthesia. Methods : In a prospective, randomized, placebo-controlled study we administered 400 mg ibuprofen (i.v.) in 42 patients scheduled for abdominal surgery. General anesthesia was combined with epidural anesthesia (T4-L1). Before as well as 5, 15, 30, 45, and 90 min after MT we recorded plasma osmolality, hemodynamics and measured 6-keto-PGFlα (stabile metabolite of PGI₂), TXB₂ (stabile metabolite of thromboxane A₂) active renin, and arginine vasopressin (AVP) plasma concentrations by radioimmunoassay. Catecholamine levels were assessed by high-pressure liquid chromatography (HPLC) with electrochemical detection. Results : Following MT, arterial hypotension occurred along with a substantial PGI₂ release. This was completely abolished by ibuprofen administration. Although plasma levels of 6-keto-PGF_1α (1133 (708) vs. 60 (3) ng/L, median (median absolute deviation), P=0.0001, placebo vs. ibuprofen) remained significantly elevated, blood pressure was restored within 30 min after MT in the placebo group. At the same point in time plasma concentrations of TXB² (164 (87) vs. 58 (1) ng/L, P=0.0001), epinephrine (46 (33) vs. 14 (6) ng/L, P=0.001), AVP (41 ± (18) vs. 12 (7) ng/L, P=0.0004), and active renin (27 (12) vs. 12 (4) ng/L, P = 0.001) were significantly higher in placebo-treated patients. Conclusion : Under combined general and epidural anesthesia arterial hypotension following MT due to endogenous PGI₂ release is associated with enhanced release of AVP, active renin, epinephrine and thromboxane A₂, presumably contributing to hemodynamic stability within 30 min after MT.     

A Teaspoon Pump for Pumping Blood with High Hydraulic Efficiency and Low Hemolysis Potential

Abstract: Virtually all blood pumps contain some kind of rubbing, sliding, closely moving machinery surfaces that are exposed to the blood being pumped. These valves, internal bearings, magnetic bearing position sensors, and shaft seals cause most of the problems with blood pumps. The original teaspoon pump design prevented the rubbing, sliding machinery surfaces from contacting the blood. However, the hydraulic efficiency was low because the blood was able to "slip around" the rotating impeller so that the blood itself never rotated fast enough to develop adequate pressure. An improved teaspoon blood pump has been designed and tested and has shown acceptable hydraulic performance and low hemolysis potential. The new pump uses a nonrotating "swinging" hose as the pump impeller. The fluid enters the pump through the center of the swinging hose; therefore, there can be no fluid slip between the revolving blood and the revolving impeller. The new pump uses an impeller that is comparable to a flexible garden hose. If the free end of the hose were swung around in a circle like half of a jump rope, the fluid inside the hose would rotate and develop pressure even though the hose impeller itself did not "rotate"; therefore, no rotating shaft seal or internal bearings are required.     

Microspheres Based Detoxification System: A New Method in Convective Blood Purification

Abstract: A variety of protein-bound or hydrophobic substances, accumulating as a result of pathologic conditions such as exogenous or endogenous intoxications, are removed poorly by conventional detoxification methods because of low accessibility (hemodialysis), insufficient adsorption capabilities (hemosorption), low efficiency (peritoneal dialysis), or economic limitations (high-volume plasmapheresis). Combining advantages of existing methods with microspheric technology, a module-based system was designed. Major operating parameters of the latter can be modified to allow for adjustment to individual clinical situations. An extracorporeal blood circuit including a plasmafilter is combined with a secondary high-velocity plasma circuit driven by a centrifugal pump. Different microspheric adsorbers can be combined in one circuit or applied in sequence. Thus, a prolonged treatment can be tailored using specially designed selective adsorber materials. Comparing this system with existing methods (high-flux hemodialysis, molecular adsorbent recycling system), results from our in vitro studies and animal experiments demonstrate the superior efficiency of substance removal.     

A comparison of the inhibitory effects of four volatile anaesthetics on the metabolism of chlorzoxazone, a substrate for CYP2E1, in rabbits

Background: Halothane inhibits in vitro and in vivo activity of cytochrome P-450 (CYP) 2E1. There are several fluorinated volatile anaesthetics besides halothane, and most of them are defluorinated by CYP2E1. It is unclear whether other fluorinated anaesthetics inhibit the in vivo activity of CYP2E1.
Methods: We compared the inhibitory effects of therapeutic concentrations of four inhalational anaesthetics, halothane, enflurane, isoflurane, and sevoflurane, on chlorzoxazone metabolism in rabbits receiving artificial ventilation.
Results: All four inhalational anaesthetics decreased arterial blood pressure and increased plasma chlorzoxazone concentration. However, no significant differences in the plasma chlorzoxazone concentration were found between the four anaesthetics. The estimated chlorzoxazone clearance increased after beginning inhalation with all four agents, but no significant difference in clearance was noted between agents.
Conclusions: At therapeutic concentrations, the in vivo inhibitory effect on chlorzoxazone metabolism was similar for all four inhalational anaesthetics examined, even though their chemical characteristics and extent of hepatic metabolism differ considerably.     

Tissue perfusion in relation to cardiac output during continuous positive-pressure ventilation and administration of propranolol or verapamil

Background : Our objective was to determine whether administration of propranolol or verapamil modifies the hemodynamic adaptation to continuous positive-pressure ventilation (CPPV), in particular the regional distribution of cardiac output (CO).
Methods : General hemodynamics and regional blood flows assessed by microsphere technique (15 (μm) were recorded in 16 anesthetized pigs during spontaneous breathing (SB) and CPPV with 8 cm H₂O end-expiratory pressure (CPPV8) before and after intravenous administration of propranolol (0.3 mg · kg⁻¹ followed by 0.15 mg · kg⁻¹ · h⁻¹, n=8) or verapamil (0.1 mg · kg⁻¹ followed by 0.3 mg · kg⁻¹ · h⁻¹, n=8).
Results : CPPV8 depressed CO by 25% without shifts in its relative distribution with the exception of a noteworthy increase in adrenal perfusion. Propranolol increased arterial blood pressure, and due to a fall in heart rate, CO dropped by 25%. The kidneys and, to a lesser extent, the splanchic region and central nervous system received increased fractions of the remaining CO at the expense of skeletal muscle flow. Similar patterns were seen during SB and CPPV8 such that the combination of propranolol and CPPV8 depressed CO by 50%. The circulatory effects of verapamil were less evident but myocardial perfusion tended to increase.
Conclusions : The combination of propranolol or verapamil with CPPV does not result in any specific hemodynamic interaction in anesthetized pigs, except that the combined effect of propranolol and CPPV may severely reduce CO.     

Bariatric Surgery in Some "Central and East-European (former Eastern bloc)"Countries - Current Status and Prediction for the Next Millennium

Background: Obesity is increasing globallly, including in the formerly "Eastern Bloc" countries. Methods: A survey was made of obesity and bariatric surgery. Results: In the 8 East and Central European countries studied, with total population 300 million, roughly 43% of the population was overweight (BMI 25-30), 23% obese (BMI > 30), with about 15 million people morbidly obese (BMI > 40). From 0-10 morbidly obese individuals/100,000/year undergo bariatric surgery. Conclusion: Most countries were found to provide inadequate treatment for obesity.The majority of the morbidly obese are not treated effectively. However, health-care awareness of obesity and bariatric surgeons are slowly increasing.     

Volatile anaesthetics reduce adhesion of blood platelets under low-flow conditions in the coronary system of isolated guinea pig hearts

Background : Inhibitory effects of volatile anaesthetics on platelet aggregation have been demonstrated in several studies. However, the influence of volatile anaesthetics on intracoronary platelet adhesion has not been elucidated so far.
Methods : Isolated hearts of guinea pigs were perfused with buffer in the absence or presence of volatile anaesthetics (0.5 and 1 MAC) at constant coronary flow rates of 5 ml/min for 25 min, then 1 ml/min for 30 min and again 5 ml/min for 10 min. Before, during and after low-flow perfusion, a bolus of human platelets was applied into the coronary system. To simulate thrombogenic conditions, 0.3 U/ml human thrombin was infused during low-flow perfusion and reperfusion. The number of platelets sequestered to the endothelium was calculated from the difference between coronary in- and output of platelets. The myocardial production of lactate and consumption of pyruvate and coronary perfusion pressure were also determined.
Results : At a flow rate of 5 ml/min only about 3% of the applied platelets did not emerge from the coronary system, in any group. In contrast, 13.1±1.2% (mean±SEM) of infused platelets became adherent in low-flow perfusion in the control group without anaesthetic. The adherence was reduced with each 1 MAC isoflurane (to 6.2±1.2%), sevoflurane (to 4.4±0.9%) or halothane (to 3.2±1.5%) (each P <0.05 vs. control). Volatile anaesthetic, 0.5 MAC, did not inhibit platelet adhesion to a statistically significant extent in any case. Perfusion pressure and metabolic parameters were not statistically different between the control and the hearts exposed to anaesthetics.
Conclusion : Volatile anaesthetics in a concentration of 1 MAC can reduce the adhesion of platelets in the coronary system under reduced flow conditions. This action does not arise from vasodilation or inhibition of ischaemic stress.     

Synergistic interaction between the effects of propofol and midazolam with fentanyl on phrenic nerve activity in rabbits

Background: It has been shown that the depressive effects of both propofol and midazolam on consciousness are synergistic with opioids, but the nature of their interactions on other physiological systems, e. g. respiration, has not been fully investigated. The present study examined the effect of propofol and midazolam alone and in combination with fentanyl on phrenic nerve activity (PNA) and whether such interactions are additive or synergistic. Methods: PNA was recorded in 27 anaesthetised and artificially ventilated rabbits. In three groups, propofol, fentanyl and midazolam were administered intravenously in incremental doses to construct dose-response curves for the depressant effects of each one on PNA. In another two groups, the effect of pretreatment with either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. on the effects of propofol and fentanyl respectively on PNA were studied. Results: Propofol and fentanyl caused a dose-dependent depression of PNA with complete abolition at the highest total doses of 16 mg · kg^?1 i. v. and 32 μg · kg^?1 i. v., respectively. In contrast, midazolam in incremental doses to a total of 0.8 mg · kg^?1 reduced mean PNA by 63%, but approximately 12% of PNA remained at a total dose as high as 6.4 mg · kg^?1. The mean ED₅₀s, calculated from dose-response curves, were 5.4 mg · kg^?1, 3.9 μg · kg^?1 and 0.4 mg · kg^?1 for propofol, fentanyl and midazolam, respectively. Initial doses of either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. acted synergistically with subsequent doses of either propofol or fentanyl to abolish PNA at total doses of 8 mg · kg^?1 and 8 μg · kg^?1, respectively. Conclusion: Fentanyl has a synergistic interaction with both propofol and midazolam on PNA and hence potentially on respiration.     

Influence of dopexamine hydrochloride on haemodynamics and regulators of circulation in patients undergoing major abdominal surgery

Background: Catecholaminergic support is often used to improve haemodynamics in patients undergoing major abdominal surgery. Dopexamine is a synthetic vasoactive catecholamine with beneficial microcirculatory properties. Methods: The influence of perioperative administration of dopexamine on cardiorespiratory data and important regulators of macro- and microcirculation were studied in 30 patients undergoing Whipple pancreaticduodenectomy. The patients received randomized and blinded either 2 μg · kg^?1 · min^?1 of dopexamine (n=15) or placebo (n=15, control group). The infusion was started after induction of anaesthesia and continued until the morning of the first postoperative day. Endothelin-1 (ET-1), vasopressin, atrial natriuretic peptide (ANP), and catecholamine plasma levels were measured from arterial blood samples. Measurements were carried out after induction of anaesthesia, 2 h after onset of surgery, at the end of surgery, 2 h after surgery, and on the morning of the first postoperative day. Results: Cardiac index (CI) increased significantly in the dopexamine group (from 2.61±0.41 to 4.57±0.78 1 · min^?1 · m^?2) and remained elevated until the morning of the first postoperative day. Oxygen delivery index (DO₂I) and oxygen consumption index (VO₂I) were also significantly increased in the dopexamine group (DO₂I: from 416±91 to 717±110 ml/m² · m²; VO₂I: from 98±25 to 157±22 ml/m² · m²), being significantly higher than in the control group. pHi remained stable only in the dopexamine patients, indicating adequate splanchnic perfusion. Vasopressive regulators of circulation increased significantly only in the untreated control patients (vasopressin: from 4.37±1.1 to 35.9±12.1 pg/ml; ET-1: from 2.88±0.91 to 6.91±1.20 pg/ml). Conclusion: Patients undergoing major abdominal surgery may profit from prophylactic perioperative administration of dopexamine hydrochloride in the form of improved haemodynamics and oxygenation as well as beneficial influence on important regulators of organ blood flow.     

Systemic analgesia adapted to the children's condition

A concept of balanced analgesia using nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol (acetaminophen), opioids, and corticosteroids can also be used in patients with pre-existing illnesses. NSAIDs are the most effective treatment for acute pain of moderate intensity in children; however, these drugs should be avoided in patients at increased risk for serious side effects, e.g. patients with renal impairment, bleeding tendency, or extreme prematurity. NSAIDs can be given with minimal risks to the younger child with mild to moderate asthma, and, in these patients, the use of steroids can be encouraged; in addition to their antiemetic and analgesic action, a beneficial effect on asthma symptoms can be expected. In the non-intubated child with cerebral trauma, exaggerated sedation caused by opioids and increased bleeding tendency caused by NSAIDs must be avoided. In neonates and small infants, the oral administration of sucrose or glucose is helpful to minimize pain reaction during short uncomfortable interventions.