Elektronik Olay Bildirim Sistemi Üzerinden Raporlanan Hasta Düşmelerinin Değerlendirilmesi

Year 2022, , 101 - 105, 30.06.2022

Yasemin Aslan Mehveş Tarım

https://doi.org/10.5152/JANHS.2022.758694

Abstract

Amaç: Bu araştırma, bir üniversite hastanesinde elektronik olay bildirim sistemi üzerinden raporlanan yatan hasta düşmelerinin değerlendirilmesi amacıyla yapılmıştır.

Yöntemler: Tanımlayıcı tipte restrospektif bir araştırmadır. Çalışmanın evrenini İstanbul’da yer
alan bir üniversite hastanesinde 01.01.2015-30.06.2017 tarihleri arasında elektronik olay bildirim
sistemi üzerinden raporlanan 159 yatan hasta düşmesiyle ilgili olay bildirim kaydı oluşturmaktadır. Araştırmada örneklem seçimine gidilmemiş ve evrenin tümü örnekleme alınmıştır. Araştırma
öncesi kurum izni ve etik kurul onayı alınmıştır. Verilerin analizinde, olayların hastalar üzerindeki
zarar derecesi için “Dünya Sağlık Örgütü Hasta Güvenliği Uluslararası Sınıflandırma Sistemi Zarar
Dereceleri” kullanılmıştır.

Bulgular: Hasta düşmelerinin bütün bildirimler içerisindeki oranının %10,6 olduğu saptanmıştır.
Hastaların %73,6’sının yetişkin, %26,4’ünün pediatrik grupta yer aldığı tespit edilmiştir. Hastaların
en fazla mobilize olurken (%78,6) ve oda içerisinde (%56) düştüğü belirlenmiştir. Hastaların düşmesini tetikleyen unsurlar değerlendirildiğinde; %39’unun denge kaybı-güçsüzlük, %25,2’sinin
baş dönmesi, %5,7’sinin ıslak/kaygan zemin nedeniyle düştüğü saptanmıştır. Olay bildirimlerin
%16,4’ünde hastaların düşmesini tetikleyen herhangi bir unsurun belirtilmediği görülmüştür.
Düşme neticesinde hastaların %34,6’sının herhangi bir zarar görmediği, %45,9’unun hafif zarar,
%1,9’unun şiddetli zarar gördüğü tespit edilmiştir.

Sonuç: Hastaların en fazla oda içerisinde, mobilize olurken, denge kaybı-güçsüzlük ve baş dönmesi nedeniyle düştüğü tespit edilmiştir Hasta düşmeleriyle ilgili ihtiyaç duyulan bütün bilgileri
içeren olay bildirim sistemleri, düşme kaynaklı yaşanabilecek olaylar için düzeltici eylem fırsatı
sunabilir.

Keywords

Zarar derecesi, olay bildirim, hasta düşmesi, hasta güvenliği

Evaluation of Patient Falls Reported through the Electronic Incident Reporting System

Abstract

Objective: This research was performed in order to evaluate inpatient falls, which were reported through the electronic incident reporting system in a university hospital.

Methods: This research is a descriptive, retrospective study. The population of the study consists of the incident reporting registry, which was reported through the electronic incident reporting
system between January 1, 2015, and June 30, 2017, in a university hospital in Istanbul, regarding the falls of 159 inpatients. In the research, no additional sample selection was made and the
entire population was regarded as the sample. Institution permission and ethics committee approval was received before conducting the research. In the analysis of the data, “World Health
Organization International Classification for Patient Safety and Severity Scale of Harm” was used to describe the severity of injury for patients.

Results: The fall rate of patients among all reports was found to be 10.6%. It was determined that 73.6% of the patients were in the adult group, while 26.4% of them were in the pediatric group. It
was identified that the patients fell mostly while being mobilized (78.6%) and in the ward (56%). When the factors that induced the fall of patients were examined; it was detected that 39% of the
patients fell due to loss of balance-weakness, while 25.2% of them fell because of dizziness and 5.7% of them due to wet/slippery floor. It was noticed that any factors that caused patients to fall were not specified in 16.4% of the incident reports. It was determined that 34.6% of the patients were not injured, whereas 45.9% of them were harmed mildly and 1.9% of them were harmed severely by cause of falling.

Conclusion: It has been found out that the patients fell mostly due to loss of balance, weakness, and dizziness during being mobilized in the ward. Incident reporting systems, which include all the information needed about patient falls, can provide an opportunity for corrective action for incidents that may occur due to falls.

Keywords

Harm, incident reporting, patient fall, patient safety

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