Abstract
Güvenlik Raporlama Sistemi Üzerinden Bildirimi Yapılan Basınç Ülserlerinin Değerlendirilmesi
ÖZ
Amaç: Sağlık kurumlarında en sık karşılaşılan hasta güvenliği olaylarından biri basınç ülserleridir. Basınç ülserleri hastaların ağrı çekmesine, tedavi süreçlerinin uzamasına, hastaların yaşam kalitesinde düşmeye, mortaliteye ve sağlık bakım maliyetlerinin artmasına neden olmaktadır. Bu çalışmanın amacı bir üniversite hastanesinde güvenlik raporlama sistemi üzerinden bildirimi yapılan basınç ülserlerinin bütün bildirimler içerisindeki oranını belirlemek, basınç ülserlerini evre, bölge ve hasta üzerindeki zarar derecelerine göre değerlendirmektir.
Gereç ve Yöntem: Araştırmanın evrenini İstanbul Anadolu Yakası’nda yer alan bir üniversite hastanesinde 01.01.2015-30.06.2017 tarihleri arasında güvenlik raporlama sistemi üzerinden elektronik olarak raporlanan basınç ülserleri oluşturmaktadır.
Bulgular: Araştırma bulgularına göre toplam 165 basınç ülseri kaynaklı olay bildirim yapılmıştır. Bütün bildirimler içerisinde basınç ülseri bildirim oranının %11 olduğu görülmüştür. Bildirimlerin %70,9’unun evre 2, %12,1’inin evrelendirilemeyen, %9,1’inin evre 1, %6,7’sinin evre 3 ve %1,2’sinin evre 4 grubunda yer aldığı tespit edilmiştir. Bölgesel dağılıma bakıldığında; basınç ülserlerinin ağırlıklı olarak %24,2’sinin koksiks, %16,4’ünün gluteal, %13,9’unun sakrum, %9,1’inin eşit oranda topuk, büyük trokanter ve bölgesel olarak yaygın olduğu tespit edilmiştir. Basınç ülseri sonucu hastaların %90,91’inin orta derecede zarar gördüğü saptanmıştır. Raporlanan basınç ülserlerinin %6,7’sinde bölge belirtilmediği tespit edilmiştir.
Sonuç: Güvenlik raporlama sistemi üzerinden hasta güvenliği ile ilgili olayları raporlamak, hasta güvenliğini artırmak için önemli bir yaklaşımdır. Sonuçlar değerlendirildiğinde en fazla evre 2 basınç ülserlerinin raporlandığı, bölge olarak en sık koksiks, gluteal ve sakrum bölgelerinde basınç ülseri geliştiği tespit edilmiştir.
Anahtar Kelimeler: Basınç ülseri, güvenlik raporlama, evre 1-4.
Keywords
Supporting Institution
Araştırmayı destekleyen kurum bulunmamaktadır.
References
- KAYNAKLAR 1. Gong Y, Kang H, Wu X, Hua L. Enhancing patient safety event reporting. Appl Clin Inform 2017; 8: 893-909. 2. European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: Quick reference guide. Washington DC: National Pressure Ulcer Advisory Panel; 2009. (Çev. Yara Ostomi İnkontinans Hemşireleri Derneği). Basınç Ülserlerini Önleme: Hızlı Başvuru Kılavuzu. Aralık 2010, Ankara. 3. Bauer K, Rock K, Nazzal M, Jones O, Qu W. Pressure ulcers in the United States' inpatient population from 2008 to 2012: Results of a retrospective nationwide study. Ostomy Wound Manage 2016; 62: 30-8. 4. Edsberg LE, Black JM, Goldberg M, McNichol L, Moore L, Sieggreen M. Revised National Pressure Ulcer Advisory Panel pressure injury staging system: Revised pressure injury staging system. J Wound Ostomy Continence Nurs 2016; 43: 585-97. 5. Altunel CT, Kartal SP. Dekübit ve bası ülserleri. Akgül A, editör. Gerontolojik/65+ Deri ve Sorunları. 1. Baskı. Ankara: Türkiye Klinikleri; 2019. p.87-94. 6. Bhatttacharya S, Mishra RK. Pressure ulcers: Current understanding and newer modalities of treatment. Indian J Plast Surg. 2015; 48: 4-16. 7. Bos JVD, Rustagi K, Gray T, Halford M, Ziemkiewicz E, Shreve J. The $17.1 billion problem: The annual cost of measurable medical errors. Health Affairs 2011; 30: 596-603. 8. Abadi MBH, Hesam A, Hamed A, Mohammad GF, Mohammad G. The association of nursing workloads, organizational, and individual factors with adverse patient outcome. Iranian Red Crescent Medical Journal 2017; 19: 1-14. 9. Moore Z. Patient safety and pressure ulcers. EWMA Policy Paper EWMA Journal 2013; 13: 63-4. 10. WHO. Patient safety fact file. Patient Safety and Risc Management Service Delivery and Safety. September 2019. 11. Slawomirski L, Auraaen A, Klazinga N. The economics of patient safety. OECD, 2017. 12. Özata M, Altunkan H. Hastanelerde tıbbi hata görülme sıklıkları, tıbbi hata türleri ve tıbbi hata nedenlerinin belirlenmesi: Konya örneği. Tıp Araştırmaları Dergisi 2010; 8: 100-11. 13. Al-Kandari F, Thomas D. Perceived adverse patient outcomes correlated to nurses' workload in medical and surgical wards of selected hospitals in Kuwait. J Clin Nurs 2009; 18: 581-90. 14. Shreve J, Bos JVD, Gray T, Halford M, Rustagi K, Ziemkiewicz E. The economic measurement of medical errors. Society of Actuaries’ Health Section. Milliman 2010: 1-10. 15. Levinson DR. Adverse events in skilled nursing facilities: National incidence among Medicare beneficiaries. The Department of Health and Human Services, United States of America. 2014. 16. Mallow PJ, Pandya B, Horblyuk R, Kaplan HS. Prevalence and cost of hospital medical errors in the general and elderly United States populations. Journal of Medical Economics 2013; 16: 1367-78. 17. Ramirez E, Martin A, Villan Y, et al. Effectiveness and limitations of an incident reporting system analyzed by local clinical safety leaders in a tertiary hospital. Prospective evaluation through real-time observations of patient safety incidents. Medicine 2018; 97: 38(e12509). 18. Stavropoulou C, Doherty C, Tosey P. How effective are incident-reporting systems for improving patient safety? A systematic literature review. The Milbank Quarterly 2015; 93: 826-66. 19. Whitson T, Garten B, Ordway GY. Indiana medical error reporting system. Final Report for 2012. Indiana State Department of Health. Published by the Indiana State Department of Health, Indianapolis 2013: 31. 20. NICE. Quality standards and indicators briefing paper. 2014: 3. 21. State of New Hampshire Adverse event reporting 2017 report. Provided by New Hampshire Department of Health and Human Services. September 2018: 4. 22. Maine Center for Disease Control and Prevention Department of Health and Human Services. Sentinel events CY2017 annual report to the Maine State Legislature. 2018: 13. 23. Hogan LJ, Rutherford BK, Mitchell VT, Ny PTN. Maryland Hospital patient safety program annual report fiscal year 2015. Department of Health and Mental Hygiene Office of Health Care Quality. 2016: 4. 24. Danish Society for Patient Safety, learning from the Danish safer hospital programme. 2015:25. 25. Parra DI, Camargo-Figuera FA, Rey Gomez R. Adverse events arising from bursing care: Phlebitis, pressure ulcers and falls. Enfermeria Global 2012; 28: 170-9. 26. Gencer ZE, Özkan Ö. Basınç ülserleri sürveyans raporu. Türk Yoğun Bakım Derneği Dergisi. 2015; 13: 26-30. 27. Esen O, Öncül S, Yılmaz M, Esen HK. Retrospective evaluation of pressure sores of patients in ıntensive care. South. Clin Ist Euras 2016; 27: 111-5. 28. Ersoy EO, Öcal S, Öz A, Yılmaz P, Arsava B, Topeli A. Yoğun bakım hastalarında bası yarası gelişiminde rol oynayabilecek risk faktörlerinin değerlendirmesi. Yoğun Bakım Derg 2013; 4: 9-12. 29. Karslı PB, Gürçay E, Cankurtaran D, Karaahmet ÖZ, Çakcı A. Bası yaralarının evre düzeylerini etkileyen faktörler. J PMR Sci 2016; 19:154-9. 30. Jiang Q, Li X, Qu X, et al. The incidence, risk factors and characteristics of pressure ulcers in hospitalized patients in China. Int J Clin Exp Pathol 2014; 7: 2587-94. 31. Bredesen IM, Bjøro K, Gunningberg L, Hofoss D. The prevalence, prevention and multilevel variance of pressure ulcers in Norwegian hospitals: A cross-sectional study. International Journal of Nursing Studies 2015; 52: 149-56. 32. Weiskopf NG, Weng C. Methods and dimensions of electronic health record data quality assessment: enabling reuse for clinical research. J Am Med Inform Assoc 2013; 20: 144-51. 33. Orhan B. Basınç yaralarını önleme kılavuzu: Kanıta dayalı uygulamalar. Arşiv Kaynak Tarama Dergisi 2017; 26: 427-40. 34. Cho E, Chin DL, Kim S, Hong O. The relationships of nurse staffing level and work environment with patient adverse events. J Nurse Schoolars 2016; 48: 74-82.
Abstract
References
- KAYNAKLAR 1. Gong Y, Kang H, Wu X, Hua L. Enhancing patient safety event reporting. Appl Clin Inform 2017; 8: 893-909. 2. European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: Quick reference guide. Washington DC: National Pressure Ulcer Advisory Panel; 2009. (Çev. Yara Ostomi İnkontinans Hemşireleri Derneği). Basınç Ülserlerini Önleme: Hızlı Başvuru Kılavuzu. Aralık 2010, Ankara. 3. Bauer K, Rock K, Nazzal M, Jones O, Qu W. Pressure ulcers in the United States' inpatient population from 2008 to 2012: Results of a retrospective nationwide study. Ostomy Wound Manage 2016; 62: 30-8. 4. Edsberg LE, Black JM, Goldberg M, McNichol L, Moore L, Sieggreen M. Revised National Pressure Ulcer Advisory Panel pressure injury staging system: Revised pressure injury staging system. J Wound Ostomy Continence Nurs 2016; 43: 585-97. 5. Altunel CT, Kartal SP. Dekübit ve bası ülserleri. Akgül A, editör. Gerontolojik/65+ Deri ve Sorunları. 1. Baskı. Ankara: Türkiye Klinikleri; 2019. p.87-94. 6. Bhatttacharya S, Mishra RK. Pressure ulcers: Current understanding and newer modalities of treatment. Indian J Plast Surg. 2015; 48: 4-16. 7. Bos JVD, Rustagi K, Gray T, Halford M, Ziemkiewicz E, Shreve J. The $17.1 billion problem: The annual cost of measurable medical errors. Health Affairs 2011; 30: 596-603. 8. Abadi MBH, Hesam A, Hamed A, Mohammad GF, Mohammad G. The association of nursing workloads, organizational, and individual factors with adverse patient outcome. Iranian Red Crescent Medical Journal 2017; 19: 1-14. 9. Moore Z. Patient safety and pressure ulcers. EWMA Policy Paper EWMA Journal 2013; 13: 63-4. 10. WHO. Patient safety fact file. Patient Safety and Risc Management Service Delivery and Safety. September 2019. 11. Slawomirski L, Auraaen A, Klazinga N. The economics of patient safety. OECD, 2017. 12. Özata M, Altunkan H. Hastanelerde tıbbi hata görülme sıklıkları, tıbbi hata türleri ve tıbbi hata nedenlerinin belirlenmesi: Konya örneği. Tıp Araştırmaları Dergisi 2010; 8: 100-11. 13. Al-Kandari F, Thomas D. Perceived adverse patient outcomes correlated to nurses' workload in medical and surgical wards of selected hospitals in Kuwait. J Clin Nurs 2009; 18: 581-90. 14. Shreve J, Bos JVD, Gray T, Halford M, Rustagi K, Ziemkiewicz E. The economic measurement of medical errors. Society of Actuaries’ Health Section. Milliman 2010: 1-10. 15. Levinson DR. Adverse events in skilled nursing facilities: National incidence among Medicare beneficiaries. The Department of Health and Human Services, United States of America. 2014. 16. Mallow PJ, Pandya B, Horblyuk R, Kaplan HS. Prevalence and cost of hospital medical errors in the general and elderly United States populations. Journal of Medical Economics 2013; 16: 1367-78. 17. Ramirez E, Martin A, Villan Y, et al. Effectiveness and limitations of an incident reporting system analyzed by local clinical safety leaders in a tertiary hospital. Prospective evaluation through real-time observations of patient safety incidents. Medicine 2018; 97: 38(e12509). 18. Stavropoulou C, Doherty C, Tosey P. How effective are incident-reporting systems for improving patient safety? A systematic literature review. The Milbank Quarterly 2015; 93: 826-66. 19. Whitson T, Garten B, Ordway GY. Indiana medical error reporting system. Final Report for 2012. Indiana State Department of Health. Published by the Indiana State Department of Health, Indianapolis 2013: 31. 20. NICE. Quality standards and indicators briefing paper. 2014: 3. 21. State of New Hampshire Adverse event reporting 2017 report. Provided by New Hampshire Department of Health and Human Services. September 2018: 4. 22. Maine Center for Disease Control and Prevention Department of Health and Human Services. Sentinel events CY2017 annual report to the Maine State Legislature. 2018: 13. 23. Hogan LJ, Rutherford BK, Mitchell VT, Ny PTN. Maryland Hospital patient safety program annual report fiscal year 2015. Department of Health and Mental Hygiene Office of Health Care Quality. 2016: 4. 24. Danish Society for Patient Safety, learning from the Danish safer hospital programme. 2015:25. 25. Parra DI, Camargo-Figuera FA, Rey Gomez R. Adverse events arising from bursing care: Phlebitis, pressure ulcers and falls. Enfermeria Global 2012; 28: 170-9. 26. Gencer ZE, Özkan Ö. Basınç ülserleri sürveyans raporu. Türk Yoğun Bakım Derneği Dergisi. 2015; 13: 26-30. 27. Esen O, Öncül S, Yılmaz M, Esen HK. Retrospective evaluation of pressure sores of patients in ıntensive care. South. Clin Ist Euras 2016; 27: 111-5. 28. Ersoy EO, Öcal S, Öz A, Yılmaz P, Arsava B, Topeli A. Yoğun bakım hastalarında bası yarası gelişiminde rol oynayabilecek risk faktörlerinin değerlendirmesi. Yoğun Bakım Derg 2013; 4: 9-12. 29. Karslı PB, Gürçay E, Cankurtaran D, Karaahmet ÖZ, Çakcı A. Bası yaralarının evre düzeylerini etkileyen faktörler. J PMR Sci 2016; 19:154-9. 30. Jiang Q, Li X, Qu X, et al. The incidence, risk factors and characteristics of pressure ulcers in hospitalized patients in China. Int J Clin Exp Pathol 2014; 7: 2587-94. 31. Bredesen IM, Bjøro K, Gunningberg L, Hofoss D. The prevalence, prevention and multilevel variance of pressure ulcers in Norwegian hospitals: A cross-sectional study. International Journal of Nursing Studies 2015; 52: 149-56. 32. Weiskopf NG, Weng C. Methods and dimensions of electronic health record data quality assessment: enabling reuse for clinical research. J Am Med Inform Assoc 2013; 20: 144-51. 33. Orhan B. Basınç yaralarını önleme kılavuzu: Kanıta dayalı uygulamalar. Arşiv Kaynak Tarama Dergisi 2017; 26: 427-40. 34. Cho E, Chin DL, Kim S, Hong O. The relationships of nurse staffing level and work environment with patient adverse events. J Nurse Schoolars 2016; 48: 74-82.
Details
| Primary Language | Turkish |
|---|---|
| Subjects | Health Care Administration |
| Journal Section | Original Article |
| Authors | |
| Publication Date | March 26, 2020 |
| Published in Issue | Year 2020 Volume: 2 Issue: 2 |
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