目的 分析死亡与并发症病例讨论会(Mortality and Morbidity Conferences,MMC)制度在医院相关性静脉血栓栓塞症(venous thromboembolism,VTE)防治中的应用效果,为医院系统落实VTE防治措施提供参考.方法 选取北京市某三级综合医院于2023年8-9月实施的两次MMC,运用头脑风暴、根因分析等方法对会议所选取的高度可疑死于急性肺栓塞的2例病例进行剖析.结果 对VTE的认知程度不足、对VTE诊断敏感度不足、不良事件管理不到位和未确立VTE风险评估流程是导致医院相关性VTE事件发生的根本原因.结论 医院要建立VTE防治的管理组织架构,定期开展VTE培训,建立VTE信息系统,明确标准化的VTE风险评估流程,增强医务人员对患者异常情况的敏感度.
A Practical Exploration of Mortality and Morbidity Conferences in the Prevention and Treatment of VTE
Objective To analyze the effect of Mortality and Morbidity Conferences(MMC)in the prevention and treatment of hospital-related venous thromboembolism(VTE),and to provide a reference forthe implementation of prevention and treatment measures of VTE in hospitals.Methods Two MMC implemented in August-September 2023 at a tertiary genera l hospita l in Beijing were selected,and rainstorming and root cause analysis were used to profile two cases selected at the meetings that were highly suspected to have died from acute pulmonary embolism.Results Insufficient awareness of VTE,insufficient sensitivity to the diagnosis of VTE,inadequate management of adverse events and failure to establish a VTE risk assessment process are the root causes of hospital-related VTE events.Conclusion Hospitals should establish a management organisational structure for the prevention and treatment of VTE,carry out VTE training on a regular basis,set up a VTE information system,define a standardised VTE risk assessment process,and enhance the sensitivity of the medical staff to the patient's abnormalities.
Mortality and Morbidity Conferencesvenous thromboembolismprevention and treatment
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