麻醉安全与质控

医疗差错是导致全球患者死亡的第三大原因，手术麻醉不良事件全流程规范化管理是提高围手术期患者临床安全的重要环节。目前，临床麻醉与围手术期不良事件上报机制亟需加强，从临床实际需求出发、切实可行的不良事件管理体系建设有待完善。通过不良事件上报、从差错中学习，可以帮助医疗机构充分利用不良事件的宝贵资源，持续改进临床质量管理与安全管理水平。北京协和医院在麻醉科实践中探索并建立了具有针对性的围手术期麻醉不良事件网格化管理体系，涵盖从不良事件上报、处理、随访、讨论分析、反馈、数据收集与数据库建设等全流程闭环式管理各个环节，该模式已转化为科室员工的自觉行动，并形成了良性循环，有效保证了不良事件的上报率和及时反馈，显著提升了患者安全管理水平，形成了良好的科室安全文化氛围。

Medical errors rank as the third leading cause of patient death worldwide. Standardized whole-process management of patient safety incidents in surgical anesthesia is of great importance for patient safety during the perioperative period. Currently, there is an urgent need to strengthen the reporting mechanisms for patient safety incidents in clinical anesthesia and perioperative care. Meanwhile, a practical and feasible patient safety incidents management system grounded in actual clinical needs to be established. Reporting patient safety incidents and learning from errors can help healthcare institutions fully leverage the valuable resources derived from such incidents, enabling continuous improvement in clinical quality and safety management. In practice, the Department of Anesthesiology of Peking Union Medical College Hospital has explored and established a targeted grid-based management system for perioperative anesthesia patient safety incidents. This system encompasses a closed-loop, whole-process management approach, including reporting, handling, follow-up, discussion and analysis, feedback, data collection, and database development. This model has effectively ensured the reporting rate and timely feedback of patient safety incidents. It has significantly enhanced patient safety management and been beneficial to foster a positive department safety culture.