Turkiye Klinikleri Journal of Forensic Medicine and Forensic Sciences

.: ORIGINAL RESEARCH
Fatsa Devlet Hastanesi Ameliyathane Biriminde Risk Analizi Yöntemiyle Ramak Kala Olayların Belirlenmesi ve Değerlendirilmesi
Fatsa State Hospital Operating Room Unit Risk Analysis Method With Determination and Evaluation of Near Misses Events
Özlem GÜRa, Vahide BAYRAKALb, A. Hüseyin BASKINb,c
aKalite Yönetim Birimi, Fatsa Devlet Hastanesi,
Ordu, TÜRKİYE
bSağlıkta Kalite Geliştirme ve Akreditasyon AD, Dokuz Eylül Üniversitesi Sağlık Bilimleri Enstitüsü,
cTemel Tıp Bilimleri Bölümü, Tıbbi Mikrobiyoloji AD, Dokuz Eylül Üniversitesi Tıp Fakültesi,
İzmir, TÜRKİYE
Turkiye Klinikleri J Foren Sci Leg Med. 2019;16(3):174-82
doi: 10.5336/forensic.2019-65635
Article Language: TR
Full Text
ÖZET
 Amaç: Sağlıkta kalite geliştirme ve akreditasyonun temel prensibi etkin, verimli, herkes için adil, güvenli ve emniyetli, hasta odaklı ve söz verilen zamanda sağlık hizmetini yerine getirmektir. Bu amaçla sağlık hizmeti verilen birimlerde ramak kala olayların belirlenip, nedenlerinin analiz edilmesi ve önlenmesi gereklidir. Fatsa Devlet Hastanesi Ameliyathane Biriminde, çalışanların ve hastaların sağlık ve güvenliklerini etkileyebilecek ramak kala olayların belirlenerek değerlendirilmesi ve bu risklerin kontrol altına alınması için risk analizini yapmaktır. Gereç ve Yöntemler: Birimde çalışan hekim, hemşire, anestezi teknisyeni, büro personeli ve destek personeli ile birlikte öncelikle iş akışları incelenip, ramak kala olaylar belirlenmiştir. Belirlenen ramak kala olaylara Dokuz Eylül Üniversitesi Risk Yönetimi Yönergesi'ne göre etki-olasılık puanlaması (10x10 matriksi kullanılmıştır) yapıldıktan sonra risk sınıflandırması yapılmıştır. Bulgular: Birim çalışanları tarafından 11 adet ramak kala olay belirlendi. Yapılan risk analizi çalışması sonunda 3 olay çok düşük düzey risk, 5 olay düşük düzey risk, 3 olay ise orta düzey risk olarak belirlenmiştir. Belirlenen ramak kala olayların alt nedenlerinde sıklıkla güvenli cerrahi kontrol listesinin etkin kullanılmadığı saptanmıştır. Güvenli cerrahi kontrol listesi (GCKL), takım çalışmasına dayanan cerrahi branşlarda kalite iyileştirme amacıyla yapılan uygulamalarda etkilidir. Doğru uygulanan GCKL, cerrahi komplikasyon ve mortaliteyi azaltmada etkili olmanın yanında iletişim ve takım çalışmasını da kolaylaştırır. Sonuç: Cerrahi bakım kalitesinin artırılması, cerrahi güvenliğin sağlanması, hasta bakımının geliştirilebilmesi, yani etkin ve güvenli bir sağlık hizmeti sunumu için güvenli cerrahi kontrol listesinin etkin bir şekilde uygulanması ve hasta odaklı çalışmanın gerekliliği kanaatine varılmıştır.

Anahtar Kelimeler: Ramak kala olay; istenmeyen olay; risk yönetimi
ABSTRACT
 Objective: The basic principle of healthcare quality improvement and accreditation is effective, efficient, equitable, safe and secure, patient centered and timely healthcare. For this purpose, it is necessary to determine the near miss events in healthcare units, to analyse the roots and causes of these events and to specify preventive measures. In Fatsa State Hospital Operation Room Unit, risk assessment studies were planned to determine and evaluate near misses events that could affect the health and safety of employes and patients and to control the risks. Material and Methods: Firstly, the people who are working in the unit the doctors, nurses, anesthesia technicians, office personnel and support personnel, with workflows were determined. According to the Risk Management Directive of Dokuz Eylul University, the risk classification was made after the impact probability score (10x10 matrix was used) was determined for the determined near misses vents. Results: Eleven different topics of near miss events were identified by the unit employees. At the end of the conducted risk analysis study, the risk level of 3 was determined as very low level risk, 5 of them as low level risk and 3 of them as medium level risk. It was determined that the safe surgical checklist was not used effectively at the lower causes of the near misses. The safe surgery checklist (SSC) is effective in quality improvement practices in team-based surgery branches. Properly applied SSC is effective in reducing surgical complications and mortality and facilitates communication and teamwork. Conclusion: As a result, it is concluded that a surgical safety checklist should be implemented effectively and patient-centered studies should be performed to increase the quality of surgical care, to provide surgical safety, to improve patient care, to provide an effective and safe healthcare service in surgical room.

Keywords: Near misses; sentinel event; risk management
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