B Y T

D N TNG CNG CHT LNG

NGUN NHN LC KHM CHA BNH

TI LIU O TO
AN TON NGI BNH

H Ni, thng 5 nm 2014

1

QUYT NH
Ban hnh ti liu o to an ton ngi bnh

BAN BIN SON

CH BIN

PGS. TS. Lng Ngc Khu

NG CH BIN:

ThS. Phm c Mc

CC TC GI:

ThS. Phm c Mc
PGS. L Th Anh Th
TS. Nguyn c Chnh
TS. V Th Thu Hng
ThS. Phm Hoi Thu

TH K:

ThS. Bi Quc Vng

MC LC
Bi 1:

Tng quan v s c y khoa khng mong mun trong cc bnh vin.....

05

Bi 2:

Phng nga s c y khoa trong vic xc nh ngi bnh v ci thin

thng tin trong nhm y t...........

19

Phng nga s c y khoa trong s dng thuc...

28

Phng nga s c y khoa trong phu thut.

45

Phng v kim sot nhim khun bnh vin...

59

Phng nga s c y khoa trong mi trng chm sc v s dng trang

thit b vt t y t

71

Bi 3:

Ph lc 1
Thng t s 19/2013/TT-BYT v hng dn qun l cht lng..

79

Bi 1
TNG QUAN V S C Y KHOA KHNG MONG MUN
TRONG CC BNH VIN
MC TIU
Sau khi hc bi ny hc vin c kh nng:
1. Gii thch c cc thut ng lin quan v an ton ngi bnh
2. Trnh by c tn sut s c y khoa v hu qu
3. Phn loi c cc nguyn nhn s c y khoa khng mong mun
4. Phn bit c li c nhn v li h thng
5. Trnh by c cc gii php bo m an ton ngi bnh
NI DUNG
1. T VN
Y vn s dng cc thut ng khc nhau m t nhng ri ro trong thc
hnh y khoa nh: Bnh do thy thuc gy nn (Iatrogenics), Sai st y khoa (Medical
Error), tai bin y khoa (Medical Complication), An ton ngi bnh (Patient SafetyAEs) v hin nay thut ng S c y khoa khng mong mun (Medical Adverse
Events) c s dng ngy cng ph bin.
Lut khm bnh, cha bnh nh ngha Tai bin trong khm bnh, cha bnh l
hu qu gy tn hi n sc khe, tnh mng ca ngi bnh do sai st chuyn mn k
thut trong khm bnh, cha bnh hoc ri ro xy ra ngoi mun trong khm bnh.
Lut khm bnh, cha bnh xc nh sai st chuyn mn khi ngi hnh ngh
vi phm mt trong nhng ni dung sau: Vi phm trch nhim trong chm sc v iu
tr ngi bnh, vi phm cc quy nh chuyn mn k thut v o c ngh nghip v
xm phm quyn ca ngi bnh.
Theo nh ngha ca WHO: S c y khoa khng mong mun l tn thng lm
cho ngi bnh mt kh nng tm thi hoc vnh vin, ko di ngy nm vin hoc
cht. Nguyn nhn do cng tc qun l khm cha bnh (health care management) hn
l do bin chng bnh ca ngi bnh. S c y khoa c th phng nga v khng th
phng nga23,25.
Tiu ch xc nh s c y khoa c s dng trong cc nghin cu ca M v
cc nc gm: (1) S c nm trong danh mc cc s c nghim trng phi bo co
theo quy nh ca M nh m t ti Ph lc s 1; (2) S c trong danh mc b t chi
tr chi ph mc cao; (3) S c dn n 1 trong 4 mc nghim trng l: Ko di
ngy nm vin, ngi bnh b tn thng vnh vin, phi can thip cp cu hoc cht.
nc ta, s c y khoa xy ra gn y gy s quan tm theo di ca ton x
hi i vi ngnh y t. p lc m cc bnh vin v ngi hnh ngh ang phi i mt
l mt s ngi nh ngi bnh v nhm ngi c toan tnh li dng s c y khoa :
(a) Gy ri lon trt t x hi (BV Nam Cn); (b) Li dng gy p lc bi thng ti
chnh (BVK Thnh ph Vinh, BV Thiu Ha); (c) Gy nh hng ti uy tn, sc
khe, tnh mng ngi hnh ngh! Trong thc t, khi c s c y khoa khng mong
mun xy ra khng ch c ngi bnh, gia nh ngi bnh tr thnh nn nhn m cc
cn b y t lin quan trc tip ti s c y khoa cng l nn nhn v cng cn c h
tr v tm l.
5

2. TN SUT V XU HNG S C Y KHOA

Cc nghin cu s c y khoa khng mong mun ca cc quc gia tin phong
c ng ti trn cc Tp ch y hc ca M, Canada, c, Anh quc, H lan v Vit
Nam c tng hp trong cc bng di y.
2.1. Tn sut s c y khoa
Bng 1. Tng hp s c y khoa ti cc nc pht trin
Nm

S NB
NC

S
s c

T l
(%)

1. M (Harvard Medical Practice Study)

1984

30.195

1.133

3,7

2. M (Utah-Colorado Study)*

1992

14.565

787

5,4

3. c (Quaility in Australia Health Case Study)

1992

14.179

2.353

16,6

4. c (Quaility in Australia Health Case Study)**

1992

14.179

1.499

10,6

5. Anh (Adverse event in British hospitals)

2000

1.014

119

10,8

6. Canada (The incidence of adverse events among

hospital patients in Canada)

2000

3.745

255

7,5

7. an Mch

1998

1.097

176

9,0

8. H Lan (Adverse Events and potentially

preventable deaths in Dutch hospitals)

2004

7.926

Nghin cu

5,7

* p dng phng php nghin cu ca c; ** p dng phng php nghin cu

ca M.
Cc nghin cu v tn sut s c y khoa ca cc quc gia tin phong bt u
t nhng nm 2000s, cc nghin cu u s dng phng php hi cu trn bnh n
v ging nhau v tiu ch nh gi cho thy tn sut s c y khoa t 3,7% -16,6%
ngi bnh nhp vin11-17. Cc nghin cu so snh p dng cng phng php ca M
v ca c cho thy tn sut s c y khoa trong khong t 5,4% - 10,6% 11,12,22,23. Vin
nghin cu y hc M hi cu 30.195 bnh n cng b t l ngi bnh nhp vin
gp s c y khoa l 3,7% 10. Cc chuyn gia y t M c tnh t nht c 44.000 98.000 ngi bnh t vong trong cc bnh vin ca M hng nm do cc s c y khoa.
S ngi cht v s c y khoa trong cc bnh vin ca M cao hn t vong do tai nn
giao thng, Ung th v, t vong do HIV/AIDS l ba vn sc khe m ngi dn
M quan tm hin nay 11,12,18-23.
Nghin cu v cht lng chm sc y t ca c (1994) do B Y t v dch v
con ngi tin hnh (1994) cng b tn sut s c y khoa i vi cc bnh nhn
nhp vin ti cc bnh vin ca c l 16,6%12.
Nghin cu s c y khoa trong cc bnh vin Anh Quc ghi nhn tn sut ngi
bnh gp s c y khoa chim 10,8% ngi bnh nhp vin v mt na s c c th
phng nga13.
6

Nghin cu v tn sut s c y khoa ti cc bnh vin Canada bo co tn sut

s c y khoa 7,5% ngi bnh nhp vin, 36,9% s c c th phng nga. Hng nm
Canada c 2,5 triu ngi bnh nhp vin v c tnh c 185.000 ngi bnh gp s
c y khoa 14.
Nghin cu v s c y khoa ti an Mch (1998) bo co tn sut s c y khoa
9% i vi ngi bnh nhp vin, 40% s c c th phng nga15.
Nghin cu ti 21/101 bnh vin H Lan (2004) bo co tn sut s c y khoa
5,7% ngi bnh nhp vin, >50% s c khng mong mun lin quan ti ngi bnh
c phu thut16.
Nghin cu ti New Zealand (1998) trn tng s 6.579 bnh n ca 13 bnh
vin i din cng b tn sut s c y khoa 6,3%. Trong , >50% lin quan ti ngi
bnh c phu thut v gn 50% s c c th phng nga, s c y khoa do li h thng
c th phng nga chim 50%17.
Bng 2. Nhim trng bnh vin ti mt s bnh vin Vit Nam
Nghin cu
Phm c Mc v cng s. Nhim khun bnh vin ti 11
bnh vin T
Nguyn Thanh H v cng s. Nhim khun bnh vin ti
6 bnh vin pha Nam.
Nguyn Vit Hng. Nhim khun bnh vin ti 36 bnh
vin pha Bc.
Nguyn Vn Xng. Nhim khun bnh vin ti bnh vin
a khoa tnh Khnh Ha..
Trn Hu Luyn. Gim st NKVM ca 1.000 NB c phu
thut ti BVTW Hu.
Trnh H Tnh v cng s. Gim st NKVM ca 622 NB c
phu thut ti BVK Bnh nh
Mai Th Tit. Gim st NKVM ca 810 NB c phu thut
ti bnh vin a khoa ng Nai
L Th Anh Th. Gim st VPBV lin quan th my ca
170 NB ti BV Ch Ry.
Phm Thi Dng, Kiu Ch Thnh. Gim st VPBV lin
quan ti th my ca 122 NB ti khoa HSCC BV103

Nm

NKBV (%)

2005

5,8

2005

5,6

2006

7,8

2013

5,4

2008

4,3

2012

8,4

2013

2,5

2011

39,4

2012

51,6

Ghi ch: Nhim trng bnh vin ti cc bnh vin Vit Nam
Nhim khun bnh vin trong cc bnh vin ca Vit Nam qua cc bo co
c ng trn cc tp ch y hc ghi nhn NKBV hin mc t 5,4% - 8% ngi bnh
ni tr, NKVM trn nhng ngi bnh c phu thut chim t 2,5% - 8,45% v vim
phi bnh vin trn cc ngi bnh c th my t 40% - 50%3,10.
2.2. Xu hng s c y khoa
Bo co ca Tng thanh tra y t M, nghin cu 780 bnh n ngu nhin ca
cc ngi bnh trong thng 10 nm 2008 cng b 13,5% ngi bnh nhp vin gp s
c y khoa (c 7 ngi bnh ra vin th c 1 ngi gp s c y khoa tha mn t nht 1
7

tiu chun xc nh s c y khoa); 51% khng th phng nga, 44% s c y khoa hu

nh c th phng nga v 5% khng xc nh18.
Nghin cu tng quan ca John T Jame ng trn Tp ch Lippincott William &
Wilkin s dng B cng c nh gi s c y khoa ca Vin ci thin chm sc y t M Global Trigger Tool of the Institute for Healthcare Improvement c tnh thp
nht 210.000 t vong hng nm lin quan ti s c y khoa so vi nghin cu ca Vin
y hc M (Institute of Medicine) nm 1999 c tnh hng nm c ti 98.000 ngi t
vong lin quan ti s c y khoa19.
Mt nghin cu hi cu trn 11.883 bnh n ca H Lan ti 20 bnh vin, trong
c 7.787 bnh n (2004) v 3.966 bnh n (2008) cng b t l s c y khoa tng
t 4,1% (2004) ln 6,2% (2008), s c y khoa i vi ngi bnh ngoi khoa tng ln
v chim t l >50% cc s c. Cc tc gi u nhn nh s c y khoa mang tnh bn
vng, s c y khoa l vn rt kh to tc ng thay i v cn thit vn ng
ngi bnh tham gia vo qu trnh lm gim s c y khoa 18,19,20.
Bo co y t ln th 9 ca Bang Minisota - M (1.2013) ghi nhn nm 2012 c
nhiu s c y khoa hn cc nm trc, bnh qun mi thng c 26,1 s c, 28% cc s
c y khoa gy hu qu cho ngi bnh v 4% s c y khoa dn n cht ngi; Cc s
c lin quan ti phu thut sai phng php, sai v tr vn c xu hng tng nh 21.
Ngoi ra, xu hng tranh chp trong khm cha bnh gia mt bn l ngi s
dng dch v y t v ngi cung cp hoc c s cung cp dch v y t ngy cng gia
tng.
3. PHN LOI S C Y KHOA
3.1. Phn loi theo tnh cht chuyn mn
Hip hi an ton ngi bnh Th gii phn loi s c y khoa theo 6 nhm gm:
- S c y khoa lin do nhm tn ngi bnh
- S c y khoa do thng tin bn giao ca CBYT khng y
- S c y khoa do sai st dng thuc: xy ra trong tt c cc cng on t khi k
n thuc, cp pht thuc, pha ch thuc, s dng thuc v theo di sau dng thuc.
Vin Nghin cu Y hc M c tnh ti M c khong 1,5 triu sai st, s c do dng
thuc xy ra hng nm v c ti 7.000 ngi cht do sai st dng thuc hng nm22.
- S c y khoa do nhm ln lin quan ti phu thut (nhm v tr, nhm phng
php, nhm ngi bnh). S c y khoa do phu thut theo c tnh ca WHO: C 25
ngi c mt ngi c phu thut, hng nm c khong 230 triu phu thut, t vong
lin quan ti phu thut t 0,4% - 0,8% v bin chng do phu thut t 3% - 16%23. S
c y khoa khng mong mun c tn sut cao trn nhng ngi bnh c phu thut
(50%)22,23,24.
- S c y khoa do nhim khun bnh vin
- S c y khoa do ngi bnh b t ng trong khi ang iu tr ti cc c s y t.
Ch : Thng t s 19 /2013/TT-BYT Hng dn thc hin qun l cht lng dch v
khm bnh, cha bnh ti bnh vin b sung thm ni dung an ton ngi bnh trong
vic s dng trang thit b y t.
3.2. Phn loi theo li c nhn v h thng
8

Li hot ng (active errors)

Nguy c

S c

Li h thng (Latent conditions)

S 1. M t cc lp hng ro bo v ca h thng phng nga s c y khoa

Ngun: Reason J. Carthey, Diagnosing vulnerable system sysdrome
Trong y t, cc quy trnh chuyn mn, cc hot ng ca thy thuc nh khm
bnh, chn an, k n, can thip th thut, k c cc hot ng hnh chnh gin tip
cng u c th gy ri ro trc tip hoc gin tip trn ngi bnh. V vy, thng quy
lm vic ca cc bnh vin, mi quy trnh cng vic cn c thit k sao cho ton b
h thng c kh nng pht hin v phng nga s c xy ra vi ngi bnh.
Cc li do c nhn ngi hnh ngh hay cn gi l li hot ng (active errors).
Ngi hnh ngh lp hng ro phng ng cui cng trc tip vi ngi bnh nn khi
s c xy ra h d b gn li. Trn thc t c nhiu li c nhn do h thng gy ra.
Theo cc nh nghin cu y khoa, 70% cc s c y khoa khng mong mun c ngun
gc t cc yu t ca h thng v ch c 30% l do c nhn ngi hnh ngh 6,12. Quy
chp trch nhim cho c nhn s dn n vn ha giu dim s tht s t hiu qu trong
vic mang li nhng kt qu di hn.
Cc li do h thng (latent factors) lin quan ti cc sai st, s c y khoa c th
l: Cc chnh sch khng ph hp, cc quy nh chuyn mn cha ly ngi bnh lm
trung tm, thiu nhn lc, ca kp ko di, thiu phng tin phc v ngi bnh, c
ch t ch v.v. Nhng yu t ny thng t c ch xem xt lin quan khi phn tch
nguyn nhn s c y khoa. Do vy nu ch tp trung vo li c nhn th nguyn nhn
gc gy ra s c vn cha c gii quyt v li tng t s tip tc xy ra.
Cc nh nghin cu a ra Hi chng h thng suy yu ca t chc
(Vulnerable System Syndrome). Hi chng ny c ba nhm triu chng chnh l: (1)
li cho c nhn trc tip (bc s, iu dng, h sinh); (2) Ph nhn s tn ti
cc im yu ca li h thng; (3) Theo ui li nhun dn n lm dng cc ch nh
chuyn mn, xa ri mc tiu ly ngi bnh lm trung tm.
3.3. Phn loi theo cc yu t lin quan
a. Yu t ngi hnh ngh
Sai st khng ch nh: (1) Do thi quen cng vic nh mt ngi pha thuc v
mt ngi tim; sao y lnh thuc; (2) Do da vo tr nh nh bc s khm bnh cho tt
c bnh nhn sau mi ghi bnh n, iu dng cui ngy mi ghi nhn xt vo h
s bnh nhn; (3) Do qun nh qun khng ly bnh phm xt nghim, qun khng
bn giao cho ca trc sau, qun khng cho ngi bnh dng thuc ng gi, ra y lnh
ming sau qun khng ghi bnh n..; (4) Do tnh cnh ca ngi hnh ngh nh
mt mi, m au, tm l; (5) Do kin thc, kinh nghim ca ngi hnh ngh. Mt
s trng hp s c y khoa khng mong mun xy ra ngay i vi cc thy thuc c
kinh nghim nht v ang trong lc thc hin cng vic chuyn mn c trch nhim.
9

Sai st do c : (1) Ct xn hoc lm tt cc quy trnh chuyn mn (cha tun

th v sinh tay, mang gng tay..); (2) Vi phm o c ngh nghip, li ch ca ngi
bnh khng c t ln hng u dn n lm dng thuc, lm dng k thut cao v
cc thit b y t can thip trn ngi bnh khng bo m cht lng.
b. Yu t chuyn mn
Y hc mang tnh xc sut v bt nh cao. Ngi bnh trong cc c s y t phi
tri qua nhiu can thip th thut, phu thut, a thuc, ha cht vo c th d gy
phn ng dn n ri ro bt kh khng. V vy, cn nhn thc khng phi s c y khoa
no cng do thy thuc thiu trch nhim v thiu y c.
Hn ch ca y hc. Nhng thnh tu y hc trong y t gip pht hin sm
bnh tt v nhiu ngi mc bnh nan y c iu tr thnh cng mang li hnh
phc cho hng triu ngi bnh. Tuy nhin, nhng hn ch ca y hc trong mt s
trng hp to nn s c y khoa nghim trng. V d, ti i Loan (2012) dng
tng ca ngi bnh HIV (+) ghp tng cho 5 ngi bnh khc.
Dy chuyn khm cha bnh phc tp. Nhiu u mi, ngt qung, nhiu c
nhn tham gia trong khi hp tc cha tt, thng tin cha y v cha kp thi.
c. Yu t mi trng chm sc y t
Mi trng chm sc y t c nhiu p lc do qu ti, ca kp tri vi sinh l bnh
thng (trong khi mi ngi ng th cn b y t phi trc). Ni lm vic cht chi
nhiu ting n, cn b y t nhiu khoa/bnh vin phi lm vic vi cng rt cao v
p lc tm l lun cng thng.
d. Yu t chnh sch, qun l v iu hnh
- Mt s chnh sch, nhng quy nh cn nghin cu iu chnh khc phc
nhng mt tri tc ng ti s an ton ngi bnh nh: Quy nh cho thuc 2-3 ngy;
ng k ni khm cha bnh ban u dn n gi ngi bnh tuyn di; thu vin
ph theo dch v dn n lm dng xt nghim, thuc, k thut cao v.v.
- C ch bnh vin t ch cng mang theo nhng ri ro tim n cn kim sot
nh: Gim chi ph u vo c bit l gim nhn lc iu dng chm sc ngi bnh,
gim s dng vt t, hng tiu hao y t, thy thuc trc khi ch nh thuc, xt
nghim cho ngi bnh phi xem xt kh nng chi tr ca ngi bnh, v.v.
- T chc cung cp dch v cha thc s hp l nh: Hot ng bnh vin tp
trung nhiu vo bui sng; ca-kp ko di (24 gi/ngy); nhn lc trc m v ngy
ngh, ngy l cha thc hin c nguyn tc Bnh vin hot ng 24 gi/ngy v 7
ngy/tun". Nhiu bnh vin tuyn huyn, b tr 1 bc s trc theo khi (ni nhi ly v
ngoi sn) dn n bc s khng p ng tt c yu cu chuyn mn chuyn khoa
(v d, bc s chuyn khoa mt trc khi ngoi khm sn v.v.). Cc yu t lin quan ti
s c y khoa c m t tm tt trong s 2 di y:

Cc yu t lin quan ti s c y khoa

10

YU T QUN L IU HNH
Chnh sch, t chc cung cp dch v, o to nhn vin, c ch vn hnh
v kim tra, gim st.
YU T MI TRNG NI LM VIC
Mi trng vt l (nh sng, nhit , ting n, ni lm vic cht hp),
qu ti cng vic, p lc tm l.
YU T CHUYN MN
Bnh bt nh, ri ro do thuc, phu thut, th thut d gy phn ng.
YU T NGI HNH NGH
Thi quen, kin thc, kinh nghim, o c ngh nghip, sc khe, tm l

S C XY RA
S 2. Cc yu t lin quan ti s c y khoa

3.4. Phn loi theo mc nghim trng i vi ngi bnh ( tham kho)
Sai st cha
xy ra
Sai st xy
ra khng gy
tn hi cho
ngi bnh

Sai st xy
ra gy tn
hi cho
ngi bnh

Hon cnh hoc tnh hung c kh nng v nguy c xy

ra sai st

S c xy ra nhng cha thc hin trn ngi bnh

S c xy vi ngi bnh nhng khng gy tn hi

S c xy ra vi ngi bnh, yu cu theo di pht

hin nguy hi hoc hoc phi can thip gim tn hi.

S c xy ra gy tn hi tm thi n ngi bnh, cn

phi thc hin cc can thip y t

S c xy ra gy tn hi tm thi n ngi bnh,

yu cu phi nhp vin hoc ko di thi gian nm vin.

S c xy ra gy tn hi vnh vin n ngi bnh,

S c xy ra vi ngi bnh, yu cu can thip y t

cn thit duy tr cuc sng ca ngi bnh.

S c xy ra gy t vong.

Ngun: NCC MERP Index, Medication Errors Council Revises and Expended Index for
categorizing Errors, June 12,2001.

3.5. S c y khoa nghim trng c s y t phi bo co (tham kho)

Bng 3. Danh mc cc s c y khoa nghim trng phi bo co28
11

1) S c do phu thut, th thut

- Phu thut nhm v tr trn ngi bnh
- Phu thut nhm ngi bnh
- Phu thut sai phng php trn ngi bnh
- St gc dng c
- T vong trong hoc ngay sau khi phu thut thng quy
2) S c do mi trng
- B shock do in git
- B bng trong khi iu tr ti bnh vin
- Chy n xy, bnh ga, ha cht c hi...
3) S c lin quan ti chm sc
- Dng nhm thuc (s c lin quan 5 ng)
- Nhm nhm mu hoc sn phm ca mu
- Sn ph chuyn d hoc chn thng i vi sn ph c nguy c thp
- Bnh nhn b ng trong thi gian nm vin
- Lot do t giai on 3-4 v xut hin trong khi nm vin
- Th tinh nhn to nhm tinh trng hoc nhm trng
- Khng ch nh xt nghim, chn on hnh nh dn n x l khng
kp thi
- H ng huyt
- Vng da tr trong 28 ngy u
- Tai bin do tim/chc d ty sng
4) S c lin quan ti qun l ngi bnh
- Giao nhm tr s sinh lc xut vin
- Ngi bnh gp s c y khoa ngoi c s y t
- Ngi bnh cht do t t, t st hoc t gy hi
5) S c lin quan ti thuc v thit b
- S dng thuc b nhim khun, thit b v cht sinh hc
- S dng cc thit b hng/thiu chnh xc trong iu tr v chm sc
- t thit b gy tc mch do khng kh
6) S c lin quan ti ti phm
- Do thy thuc, NVYT ch nh gy sai phm
- Bt cc ngi bnh
- Lm dng tnh dc i vi ngi bnh trong c s y t
Ngun: NQF, Serious Reportable Event in Health Care 2006 update.
4. XUT
12

Trn c s tng hp cc nghin cu trong nc v cc quc gia tin phong, tc

gi khuyn ngh:
1. Tng cng h thng chnh sch, vn bn php quy v ATNB: S c y
khoa cn c xem xt nh mt vn y t cng cng (public health issue) v nhng
l do sau y: (1) S c y khoa mang tnh ton cu, vt ra tm iu chnh cc sai st
mang tnh c nhn ngi hnh ngh, xy ra mi lc, mi ni, ti mi c s y t, c quy
m rng (c nhn, t chc, quc gia v quc t); (2) S c y khoa c tn sut cao
(3,7% - 10,6% ngi bnh nhp vin, hu qu s c y khoa rt nghim trng trc tip
nh hng ti kt qu iu tr, tnh mng ngi bnh, uy tn, s an ton v an ninh ca
mi c s y t; (3) Vic khc phc v lm gim s c y khoa l mt cng vic kh
khn, lu di v i hi s tham gia ca ton b h thng, k c s tham gia ca ngi
bnh v cng ng. Mi n lc ca h thng y t ch c th lm gim nh s c y khoa
m khng c th phng nga c mi s c y khoa; (4) Cn c s phi hp gia cc
ngnh ngh trong lnh vc y t v ngoi y t, c bit l cc c quan bo ch, truyn
thng trong vic cung cp thng tin tng cng nhn thc ca cng ng v ngi
hnh ngh v an ton ngi bnh. T chc Y t Th gii c Ngh quyt s
WHA55.18 ku gi cc quc gia thnh vin ginh s quan tm cao nht c th ci
thin s an ton ngi bnh. ng thi, yu cu Gim c ca T chc Y t th gii
a ra cc hng dn, cc chun ton cu v an ton ngi bnh, h tr thit lp cc
h thng o lng, bo co s c y khoa v thc hin nhng gii php lm gim rui
ro cho ngi bnh24.
2. Xem xt thnh lp cc t chc ATNB: Cc quc gia tin phong nh M,
c, Anh, Canada, New Zealand t thp k u ca th k XXI thnh lp cc t
chc chuyn trch t vn, gim st, nh gi ATNB nh: y ban quc gia v cht
lng y t v an ton ngi bnh (M, c, Malaysia ); Vin nghin cu quc gia an
ton ngi bnh (M, Canada); Hip hi an ton ngi bnh (c); C quan an ton
ngi bnh quc gia (Anh quc, M); Lin minh an ton ngi bnh c (German
Coalition for Patient Safety) v.v. Cc t chc trn ng vai tr rt quan trng trong
vic tham mu, t vn, iu phi cc n lc v ATNB.
3. Trin khai h thng bo co s c y khoa bt buc: Hin nay, nhng s c
y khoa bit ch l phn ni ca tng bng do vic thit lp h thng bo co s
c y khoa l cp thit nh gi hin trng v theo di xu hng. H thng bo co
s c y khoa bao gm cc thnh t sau: (1) Vn bn hng dn bo co s c y khoa
v quy nh s dng thng tin v s c y khoa; (2) Ban hnh danh mc cc s c y
khoa phi bo co bt buc bt c khi no v B Y t; (3) Chun ha khung Bo co
s c y khoa v bo co nh gi nh k v cc s c y khoa, phn tch nguyn nhn
gc v cc gii php khc phc. Tng bc minh bch thng tin v s c y khoa th
hin s tn trng ca cc h thng y t i vi ngi bnh v th hin trch nhim ca
cc cp ca h thng y t khi s c xy ra. Kinh nghim mt s nc tin phong, vic
cng khai minh bch thng tin v s c y khoa lm gim p lc ca cng ng i vi
ngnh y t v ngnh y t nhn c s thng cm, chia s ca ngi bnh v cng
ng v tnh cht phc tp v a dng ca s c y khoa.
4. Trin khai bo him ngh nghip. Vic trin khai bo him ngh nghip s
gip bo v ngi hnh ngh, bo v c s y t. Khi s c y khoa xy ra, c quan bo
him c trch nhim gii quyt bi thng cho ngi bnh v s c tc ng lm tng
13

nim tin ca ngi bnh v gia nh ngi bnh v kh nng n b khi c s c xy

ra v t s gim bt gy cng thng cho thy thuc v c s y t.
5. Ci thin mi trng lm vic v vn ha an ton ngi bnh: Bo m
nhn lc p ng yu cu bnh vin hot ng lin tc 24 gi/ngy v 7 ngy/tun. R
sot li cc thng quy lm vic (khm bnh, k n, pht thuc, bn giao ca kp...)
pht hin cc khong trng c nguy c tim tng ti s ATNB ch ng khc phc,
r sot v cp nht cc hng dn chuyn mn, khc phc li h thng v tng cng
gio dc, kim tra s tun th ca ngi hnh ngh, tng cng chuyn nghip v lun
t li ch ca ngi bnh ln trn cc li ch ca c nhn trong khi hnh ngh.
6. Tng cng kim tra, gim st s tun th ca ngi hnh ngh. Gim
thiu cc sai st s c y khoa lin quan ti vic xc nh sai tn ngi bnh; thng tin
khng y gia cc cn b y t; sai st trong dng thuc; sai st trong phu thut,
th thut; tng cng cng tc kim sot nhim khun; s dng trang thit b y t./.
TI LIU THAM KHO
1. Lut Khm bnh, cha bnh
2. B Y t. Thng t S 19 /2013/TT-BYT Hng dn thc hin qun l cht lng dch v
khm bnh, cha bnh ti bnh vin.
3. Nguyn Thanh H (2005), Gim st nhim khun bnh vin ti 6 tnh pha Nam.
4. Nguyn Vit Hng (2005). Tnh hnh nhim khun bnh vin ti cc bnh vin khu vc
pha Bc.
5. Trn Hu Luyn. Nhim khun bnh vin trn NB c phu thut.
6. Phm c Mc v cng s (2005). Nhim khun bnh vin ti cc bnh vin trc thuc
B Y t nm 2005.
7. L Anh Th. Nhim khun bnh vin trn cc bnh nhn c th my.
8. Nguyn Vn Xng. Nhim khun bnh vin ti bnh vin a khoa tnh Khnh ha, 2013.
Tp Ch y hc thc hnh (2014), s 904: 65-69.
9. Trnh H Tnh v cng s. Gim st NKVM ca 622 NB c phu thut ti BVK Bnh
nh. Tp Ch y hc thc hnh (2014), s 904: 57-64.
10. Mai Th Tit. Gim st NKVM ca 810 ngi bnh c phu thut ti bnh vin a khoa
ng Nai. Tp Ch y hc thc hnh (2014), s 904: 53-56.
11. Results of Harvard Medical Practice Study II. New England Journal of Medicine,
1991,323:377.384.
12. Wilson, R.M., Runciman W.B., Gibberd R.w., Newby,L., & Hamilton, J.D. (1995). The
quality in Austrailia health care Study. The medical Journal of Australia,163 (9), 458-471.
13. Vincent, C., Neale, G., & Woloshynowych,M. (2001). An adverse events in British
hyospitals: Preliminary retrospective record review. British Medical Journal, 322 (7285),
517-519.
14. Baker, G.R., Norton P.G., Flintoft, W., Blais, R., Cox,J., et al. (2004). The Canadian
adverse event study: The incident of adverse events among hospital patient in Canada,
CM,170 (11), 1678-1686
15. Mette Lundgaard, Louise Raboel, Elizabeth Broegger Jensen. Danish Society for patient
Safety. The Danish patient experience: the Act on patient safety in the Danish health care
system.
16. M Zegers, M C de Bruijne, C Wagner. Adverse events and potentially preventable deaths
in Dutch hospitals. Results of retrospective patient record review study.
17. Davis P, Lay-Yee R, Briant R, Ali W, Scott A, Schug S. Adverse events in New Zealand
public hospitals II: preventability and clinical context.
18. Daniel R. Levinson. Advrese events in hospitals: National incident among medical
beneficiaries. Offic of Investigator General.
14

19. Rebecca J Baines, maaike Langelaan. Change in adverse event rates in hospital over time:
a longitudinal retrospective record review study.
20. Trends in adverse events events over time: why are we not improving
21. Adverse health events in Minnesota. Ninth Annual Report/Jannuaryy 2013
22. WHO (2011). Patient Safety curriculum guide. Multi-professional Edition,2011, 96-97.
23. Vincent C et al. Systems approaches to surgical quality and safety: from concept to
measurement. Annuals of Surgery , 2004, 239:475482.
24. R. Monina Klevens, Jonathan R. Edwards, Chesley L. Richards (2002). Estimating
Health Care-Associated Infections and Deaths in U.S. Hospitals
25. WHO (2002). Fifty fifth World health Assembly WHA55.
26. WHO (2011). Guidelines for Adverse Event Reporting and Learning System
27. Bates DW, Spell N et al (1997), "The costs of adverse drug events in hospitalized
patients", JAMA 1997; 277:301-34.
28. Serious Reportable Events in health care-2011 Update: A consensus report. National
Quality forum. Washington, DC: NQF,2011

15

CU HI LNG GI
A. CHN CM T THCH HP IN VO CH TRNG
Cu 1. Theo Lut khm bnh, cha bnh: Tai bin trong khm bnh, cha bnh l hu
qu gy tn hi n sc khe, tnh mng ca ngi bnh do ..(1).. chuyn
mn k thut trong khm bnh, cha bnh hoc (2) xy ra ngoi mun
trong khm bnh.
A. Vi phm
B. Sai st
C. Ri ro
D. S c
Cu 2. Theo Lut khm bnh, cha bnh: Sai st chuyn mn c xc nh khi ngi
hnh ngh vi phm mt trong nhng ni dung sau: Vi phm trch nhim trong chm
sc
v
iu
tr
ngi
bnh,
..(1)
v
(2) v xm phm quyn ca ngi bnh.
A. Cc quy nh s dng thuc
B. Cc quy nh chuyn mn k thut
C. o c ngh nghip
Cu 3. Theo nh ngha ca WHO: S c y khoa khng mong mun l tn thng lm
cho ngi bnh....(1) .. tm thi hoc vnh vin, cht hoc ko di
ngy nm vin. Nguyn nhn do (2) khm cha bnh
(health care management) hn l do bin chng ca bnh ca NB. S c y khoa c th
phng nga v khng th phng nga.
A. Mt kh nng
B. Suy gim chc nng
C. Cng tc qun l
D. Bin chng ca bnh
B. CHN 01 TR LI NG NHT
Cu 4. Tiu ch xc nh s c y khoa khng mong mun theo quy nh ca M bao
gm:
A. Cc s c trong danh sch cc s c phi bo co bt buc
B. Cc s c trong danh mc b t chi tr chi ph mc cao
C. S c dn n 1 trong 4 mc nghim trng l: ko di ngy nm vin, ngi
bnh b tn thng vnh vin, phi can thip cp cu hoc cht.
D. C A, B v C
Cu 5. Theo bo co ca T chc Y t Th gii, t l t vong lin quan ti phu thut
l:
A. 0,4% - 0,8% ngi bnh c phu thut
B. 1% - 2% ngi bnh c phu thut
C. >2% ngi bnh c phu thut
D. Tt c u sai
Cu 6. Theo bo co ca T chc Y t Th gii, t l nhim khun bnh vin i vi
16

cc nc ang pht trin t:

A. 5% - 15% ngi bnh ni tr
B. 9% - 37% ngi bnh ti cc khoa iu tr tch cc
C. 24,6% ngi bnh iu tr ti cc khoa chm sc tch cc
D. Tt c A, B v C
Cu 7. S c do phu thut, th thut bao gm:
A. Phu thut nhm v tr, nhm ngi bnh
B. Phu thut sai phng php, st gc dng c v t vong trong phu thut
thng quy
C. St gc dng c trong vt m, nhm ngi bnh
D. A v B
Cu 8. S c y khoa lin quan ti qun l ngi bnh bao gm:
A. Chy n bnh xy
B. Giao nhm tr s sinh lc xut vin,
C. S c xy ra vi NB ngoi c s y t
D. Ngi bnh cht do t t, t st hoc t gy hi
E. B, C v D
Cu 9. T chc Y t Th gii khuyn co cc gii php bo m an ton ngi
bnh bao gm:
A. 4 gii php an ton ngi bnh ton cu
B. 5 gii php an ton ngi bnh ton cu
C. 6 gii php an ton ngi bnh ton cu
D. 7 gii php an ton ngi bnh ton cu
Cu 10. B Y t M xut danh sch cc nhm s c y khoa nghim trng gm:
A. 7 nhm
B. 6 nhm
C. 5 nhm
D. 4 nhm
Cu 11. Cc nhm yu t nguyn nhn dn n s c y khoa gm:
A. Qun l v iu hnh
B. Mi trng ni lm vic
C. c im chuyn mn y t
D. Ngi hnh ngh
E. C A, B, C v D
Cu 12. Cc yu t nguy c trong nhm qun l iu hnh bao gm cc yu t di
y, TR:
A. C ch vn hnh c s khm cha bnh
B. T chc cung cp dch v
C. Kinh nghim ngi hnh ngh
D. o to
E. Kim tra gim st
17

Cu 13. Cc nhm triu chng ca Hi chng h thng suy yu gm:

A. li cho c nhn ngi trc tip
B. Khng tha nhn cc im yu ca li h thng
C. Chy theo cc mc tiu doanh thu, lm dng ch nh
D. C A, B v C
C. XC NH CU NG SAI
14
15
16
17
18
19
20

Nguyn nhn ca cc s c y khoa ch yu l do li

c nhn
Tng cng pht tr cc c nhn lin quan ti s c
y khoa s lm cho bnh vin khng cn s c y
khoa
Tt c cc s c y khoa u c th phng nga

Minh bch thng tin v s c y khoa th hin s tn

trong i vi ngi bnh
Ngi bnh c quyn c thng tin y v kp
thi v cc s c y khoa xy ra i vi h
Cn c chnh sch v hng dn quc gia v gii
quyt v bo co s c y khoa
Cn xy dng vn ha v an tan ngi bnh trong
cc c s y t

P N
Cu 1. 1= B, 2 = C

Cu 8. D

Cu 15. S

Cu 2. 1= B, 2 = C

Cu 9. C

Cu 16. S

Cu 3. 1= A, 2 = C

Cu 10. B

Cu 17.

Cu 4. D

Cu 11. E

Cu 18. ng

Cu 5. A

Cu 12. C

Cu 19.

Cu 6. D

Cu 13. D

Cu 20.

Cu 7. D

Cu 14. S

18

Bi 2
PHNG NGA S C Y KHOA TRONG VIC XC NH NGI BNH V
CI TIN THNG TIN TRONG NHM Y T
MC TIU
Sau hc bi ny hc vin c kh nng:
1. Hiu c cc nguyn tc xc nh ng ngi bnh v ci tin thng tin
trong nhm chm sc
2. p dng c cc bin php xc nh ng ngi bnh v ci tin thng tin
trong nhm chm sc
1. T VN
Theo thng k ca y ban lin hp quc t v an ton bnh nhn, cc s c xy
ra trong trao i thng tin chim n 65% ca tt c s c. S sai lc trong trao i
thng tin thng dn n gia cc nhn vin y t (NVYT) vi nhau v gia nhn vin
y t v bnh nhn thng dn n xc nh sai ngi bnh. Do , cn ci tin v gia
tng s trao i thng tin, phng nga nhng sai st, s c y khoa trong vic xc nh
ngi bnh v ci tin thng tin trong nhm chm sc.
Cc c s y t phi nhn ra c cc ro cn i vi vic trao i thng tin hiu
qu v phi trin khai cc qui trnh trao i thng tin bng li ni hoc bng vn bn
bo m chnh xc, kp thi, v hon chnh gia y bc s v tt c nhng ngi c lin
quan n vic s dng d liu. By phn trm s ngi tr li mt cuc thm d do
Vin Thc Hnh Y T An Ton tin hnh nm 2005 cho thy rng h b sai st trong
thc hin thng tin do mnh lnh khng r rng, p t. Qun l thng tin ca c s y
t hiu qu s h tr cc cc hot ng ci tin nghip v chuyn mn, v hot ng
lin quan n chm sc, iu tr, v phc v ngi bnh, cc hot ng gim ri ro.
Ci tin thng tin gia NVYT v bnh nhn cng h tr cc hot ng an ton cho
bnh nhn. T nm 1995, chin dch Hy Pht Biu Kin ca y ban Lin Hip
Quc khuyn khch bnh nhn v gia nh trao i vi ngi chm lo sc kho cho
mnh nu h c cu hi hoc bc xc v cc kha cnh cha tr v gip gim thiu
s c do thiu thng tin.
2. NGUYN TC
2.1. Qun L Thng Tin
Qun L Thng Tin bao gm thu thp, lu tr, trch xut, chuyn ti, phn tch,
kim sot, phn phi v s dng d liu hc thng tin, c trong ni b c s v vi
bn ngoi, theo ng lut php v cc qui nh. Ngoi cc thng tin bng vn bn v
li ni, cng ngh thng tin h tr v cc dch v thng tin h tr khc cng nm trong
qui trnh qun l thng tin.
Qun l thng tin h tr cho vic ra quyt nh kp thi v hiu qu tt c mi
cp ca c s. Cc qui trnh qun l thng tin h tr cc quyt nh v mt qun l
v thc hin, cc hot ng ci tin vic thc hin, v cc quyt nh v chm sc,
iu tr, v phc v bnh nhn. Vic a ra quyt nh v chuyn mn v mang tnh
chin lc tu thuc vo thng tin t nhiu ngun khc nhau, bao gm h s bnh
nhn, thng tin da trn kin thc, d liu/thng tin c tnh so snh, v d liu/thng
tin tng th.
19

 h tr vic ra quyt nh v chuyn mn, thng tin trn h s bnh nhn

phi gm cc im sau:
- Sn sng khai thc trn ton h thng
- c lu li chnh xc
- Hon chnh
- c sp xp trch xut c hiu qu cc d liu cn thit
- ng hn
- Cc d liu v thng tin mang tnh so snh v vic thc hin phi sn sng ra
quyt nh, nu p dng
- C s c kh nng thu thp v tng hp d liu v thng tin h tr vic chm
sc v phc v, gm nhng vic sau: Chm sc c nhn v chm sc ni chung, qun
tr v nghp v chuyn mn, phn tch cc xu hng theo thi gian, so snh vic thc
hin theo thi gian trong ni b c s v vi cc c s khc, ci tin nghip v chuyn
mn v kim sot nhim khun.
Qun l tt thng tin i hi:
- Khuyn khch trao i v hp tc gia bc s v iu dng hoc cc nhn vin
chm sc khc. Trnh vn ho theo th bc.
- Xy dng v khuyn khch h thng bo co khng khin trch, khuyn khch
nhn vin bo co cc tai nn, s ngng hot ng, hoc cn-s-c. C th s dng
nhng t nh tai nn hoc s ngng hot ng thay v li v trch nhim thay v
khin trch. Cho php bo co b mt hoc v danh v cc tai nn y t, cn-tai-nn, v
ri ro trong qui trnh hoc mi trng chm sc.
- Khuyn khch vic s dng nhng phng tin khng chnh qui trao i v
cc bc xc, cc vn , v cc sai st lin quan n s an ton.
- H tr vic chia s cc bi hc kinh nghim to s thay i v hnh vi bn
trong v bn ngoi c s. Chia s nhng bi hc lin quan n cc xut an ton
trong mt c s y t l mt phng php tt gip thc y mt khng gian vn ho
an ton. S chia s nh th thng qua nhng cu chuyn k v nhng giai thoi c
nhn s khin ngi nghe ch , nh ci thin c hi cho ngi nghe nm c
thng ip, c th c chia s trong cc bui hp nhn vin, cc hi ngh, thng
qua cc bi bo c xut bn, v bng vic trao i thng tin.
- Hun luyn c nng lc lm vic trong mi trng ng i v lm theo cc h
thng v qui trnh s him khi no phm sai lm nh hng n s an ton cp c
s. Do lnh o phi bo m vic hun luyn ton din v kp thi cho tt c nhn
vin trong cc qui trnh v phng thc thao tc.
- Cung cp ngun lc cn thit bo m qun l thng tin hiu qu. D liu
phi ng b, kp thi, v chnh xc, v cc phng thc thc hin v cc qui trnh
phi c lu h s cn thn nhm gim bt hoc xo b nhng bin i hon ton
khng cn thit.
2.2. Xc nh ngi bnh
2.2.1. Cc nguyn tc chung trong xc nh ngi bnh
- Cn xc nh mt cch ng tin cy c nhn chnh l ngi m ta phi chm
sc, iu tr, v phc v.
20

- Cn rp ni vic chm sc, iu tr, v phc v ca ngi bnh vi nhau.

2.2.2. Cc ni dung cn thit trong xc dnh ngi bnh
- Phi c hai mu thng tin nhn dng bnh nhn (v d, tn v ngy sinh ca
bnh nhn). C th s dng bng c tay c ghi tn v mt con s ring bit ca bnh
nhn nhn dng chnh xc bnh nhn (tn v con s ring bit l hai mu thng
tin).
- Hai cng c nhn dng c th ny phi c gn kt trc tip vi bnh nhn, v
cng hai cng c y phi c gn kt trc tip vi thuc men, cc sn phm v mu,
cc ng cha mu vt lu (chng hn trn nhn c dn vo).
2.3. Ci tin vic trao i thng tin ca nhn vin.
Trao i l qui trnh nh thng tin c trao i gia cc c nhn, cc khoa
phng, hoc cc c s. Vic trao i phi i vo mi kha cnh ca c s y t, t thc
hin vic chm sc cho n ci tin, dn n nhng tin b ng k trong cht lng
v trong vic th hin chc trch. Cc cng on ca qui trnh trao i thong tin gm
c:
- Trao i gia nh cung cp dch v y t v/hoc nhn vin y t v bnh nhn.
- Hng dn bnh nhn v gia nh h.
- Trao i v hp tc gia cc nhn vin.
- Phn phi thng tin.
- Lm vic theo i ng a ngnh.
2.3.1. Cc nguyn tc chung trong ci tin vic trao i thng tin ca nhn vin
- Lnh o bnh vin cn thng tin cho NVYT v vai tr ca ci tin vic trao i
thng tin i vi cht lng v s an ton trong chm sc sc kho.
- Tht bi trong trao i thng tin phi c nhn nhn l do li h thng hn l
quy cho bt c mt nhn vin c th no.
- NVYT phi nm c li ch ca vic lm vic nhm, s hp tc, v trao i
thng tin c c s trao i thnh cng trong cng vic.
- Ngoi vic trao i gia cc thy thuc vi nhau, v vi cc chuyn gia y t
khc, trao i gia thy thuc vi bnh nhn v gia nh h l rt cn thit. Bnh nhn
v cc thnh vin trong gia nh cng cn c gio dc v gi tr ca vic trao i
thng tin vi ngi chm sc sc kho cho mnh.
- C s y t cn phi nm chc bnh nhn l ai.
2.3.2. Cc ni dung cn thit ci tin vic trao i thng tin ca nhn vin
- Xc nh r rng cc phng php trao i thng tin c mong i. S dng
cc tin b nhiu lnh vc khc nhau ci tin vic trao i thng tin gia cc thy
thuc. Trao i trc tip gia cc nhn vin y t thng l cch tt nht mang li s
chm sc an ton, cht lng cao. S dng t liu vit tay cn trin khai v thc hin.
Ch cc ti liu vit tay nht thit phi d c.
- Xy dng h thng v qui trnh hon thin vic trao i thng tin lin quan
n nhu cu ca bnh nhn trong thi gian iu tr. Vi s tham gia ca bc s v cc

21

nhn vin iu tr khc, lnh o phi xy dng v thc hin cc h thng thng tin
chuyn ti thng tin t ngi ny qua ngi kia. Cc bo co ming trc tip v cc t
liu bng vn bn v in t l nhng th hiu qu nht. Cc bo co thu qua bng a,
mc d thng c xem l phng tin h tr, cng khng to c hi cho ngi
chm sc sau t cu hi vi ngi chm sc trc . Tuy nhin, bng a c th
c tham kho nhiu ln v bi nhiu ngi. iu cn ch l bc s v iu dng
phi nhn c tt c mi thng tin cn thit khi bt u chm sc mt ngi bnh.
Cc iu dng phi lu tr nhng im quan trng bng phng tin c trin khai
c s mnh chuyn giao cho ca trc k tip.
- Xc nh v nh ga cc phng php trao i thng tin c s dng ti c
s, bao gm ni ming, vn bn, v in t. Nhn vin nn kho st mt cch c h
thng cc phng php trao i thng tin s c s dng xc nh nhng phng
php no c th b li. Vic chm sc da trn rt nhiu s trao i bng ming v
bng vn bn v phng php no cng c th b li. Vic lu tr h s in t v vi
tnh ho vic k n thuc l hai vic gip gim rc ri lin quan n vic a ra y
lnh.
- Trin khai v thc hin cc phng thc hiu qu lin lc vi cc chuyn gia.
Lin lc nhanh chng vi cc chuyn gia v c vn l iu rt quan trng ca c s y
t ba v ngi bnh khi nhng hu qu xu v bo m iu tr c lin tc. V
d, mt bc s cp cu cn lin lc cc chuyn gia nh bc s phu thut chn thng
v bc s phu thut tim qua my nhn tin, in thoi, hoc cc phng tin khc
chm sc ng cho bnh nhn ang trong phng cp cu vi vt thng do sng n
v cn nhi mu c tim.
- Khuyn khch thc mc khi nhn y lnh khng r rng hoc mang tch cch
cng bc. Nhn vin nn c khuyn khch t cu hi v thc mc v nhng g
khng r rng hoc nhng y lnh khng thch hp.
3. BIN PHP
3.1. Ci tin s chnh xc trong vic xc nh bnh nhn
3.1.1. Bin php 1: S dng t nht hai cng c nhn dng bnh nhn (nhng c hai
u khng phi l s phng hoc s ging ca bnh nhn) bt c khi no qun l
thuc men v cc sn phm v mu, ly mu mu v cc mu khc xt nghim,
hoc lm cng tc iu tr hc bt c cng vic no khc
- C th s dng thng tin nh tn bnh nhn, ngy sinh bnh nhn, m vch lm
cng c nhn dng.
- Khi kim tra tn vi bnh nhn, nhn vin y t khng bao gi nn c tn v
yu cu bnh nhn xc nhn n. Nhng bnh nhn b nhm ln hoc ri lon hnh vi
c th ng ngay c khi khng phi l tn ca h. Cch lm an ton hn l yu
cu bnh nhn t ni tn ca h.
- Trng hp bnh nhn hn m, thn nhn ngi bnh phi xc nh nhn thn
cho h. Nu bnh nhn hn m c a n bnh vin bi cng an hoc dch v cp
cu v khng c mt chng c no v nhn thn, hi cng an hoc nhn vin cp cu
v ngi bnh, nu c th v cho h s nhp vin hoc s cp cu hoc s h s.

22

i vi cc khoa xt nghim: S dng t nht hai cng c nhn dng bnh nhn
(nhng c hai u khng l v tr ca bnh nhn) bt c khi no ly mu cho phng xt
nghim hoc qun l thuc men v cc sn phm v mu, v s dng c hai cng c
nhn dng dn nhn cho cc vt cha mu c s hin din ca bnh nhn. Cc quy
trnh c xy dng vn gi c tn ch nhn ca cc mu trong sut qu trnh
trc phn tch, ang phn tch, v sau phn tch.
3.1.2. Bin php 2: Ngay trc khi bt u bt c th thut xm ln no, cn tin hnh
qui trnh lm r sau cng xc nh chnh xc bnh nhn, phng php, v tr, v s
sn sng cc h s thch hp. Vic lm r ny phi tin hnh ni th thut c thc
hin, ngay trc giy pht bt u. Nhn thn bnh nhn c ti xc nh nu bc s
thc hin ri khi ch nm ca bnh nhn trc khi bt u th thut. nh du v
tr thao tc l iu bt buc tr khi bc s lin tc c mt t lc quyt nh tin hnh
phng thc cho n khi bt u th thut.
Ba vn sau y cn c xc nh:
- Ngi bnh chnh xc
- Phng php chnh xc
- V tr th thut chnh xc
Qui trnh lm r sau cng s dng cc k thut trao i thng tin nng ng. Tt
c nhn vin c lin quan u phi ngng li c ngha l, dng mt cht thi
gian khng thao tc lm r rng chnh l bnh nhn chnh xc, phng
php chnh xc, v v tr chnh xc.
Tt c thnh vin ca nhm thc hin phi tham gia vo qui trnh lm r cui
cng. Tt c hot ng trong phng phi ngng li mi ngi tham gia. Mi vic s
khng c bt u cho n khi bt c v tt c cc cu hi v vn u c gii
quyt. Vic thc hin phi c c to ln, chnh xc nh trn vn bn ng thc
hin. V d, ti cuc phu thut, tt c cc bc k tip trong mt ca c nhiu bc, tt
c mi hot ng phi ngng li, v mt thnh vin c ch nh, chng hn mt iu
dng vng ngoi s c to cch thc tin hnh v v tr thc hin thao tc.
Phi c chnh sch cho vic lm r sau cng v phi theo di n c vic tun
th chnh sch ny, bo m tt c thnh vin u theo ng ng li v xc nh
ng cc lnh vc ci tin.
3.1.3. Bin php 3: a bnh nhn tham gia vo trao i thng tin.
Yu cu bnh nhn nhc nh nhn vin y t xc nh nhn thn cho h. C th
yu cu cho bnh nhn tham gia vo vic nh du v tr nh mt phn ca qui trnh
trc khi thc hin th thut.
3.2. Ci tin hiu qu trao i thng tin gia nhn vin y t
3.2.1. Bin php 1: Khng khuyn khch y lnh ming. Trng hp cp cu, nu c y
lnh ming cn phi:
- Ngi nhn phi c li hoc vit ng nguyn vn cho ngi ch nh nghe v
ngi ch nh phi xc nhn bng ming ch nh l chnh xc. S tt hn nu c
ngi th ba cng xc nh y lnh ming.
- Ngi ch nh y lnh ming qua in thoi v dng thuc trong cp cu phi
yu cu ngi nhn nh vn tn thuc hoc t nh vn tn thuc bng cch dng cc
23

cch tr gip nh B nh trong qu bng, M nh trong Mary hn ch s nhm

ln i vi nhng loi thuc trng ging nhau v nghe ging nhau. Tt c con s phi
c c r rng tng s mt. V d s 21 phi c c l hai, mt trnh nhm
ln.
- Ngay sau khi ch nh v thc hin y lnh ming th ngi ch nh v ngi
thc hin phi ghi vo h s bnh n kp thi v y .
- Ngi thng tin v cc kt qu xt nghim bt thng, cc kt qu xt nghim
quan trng qua in thoi phi yu cu ngi nhn c li y kt qu xt nghim.
3.2.2. Bin php 2: Truyn t thng tin r rng
- Trnh dng ch vit tt. V d, 1v/3l/n phi c vit r l ngy 3 ln, mi
ln 1 vin.
- Y lnh phi ghi r rang, y theo ng quy nh. C th dng cc t n
thuc c in sn, cc mu n ny gip lm gim bt thi gian vit y lnh.
- Cc thuc c pht theo n phi phi c nhn, ch vit r rng nhm hn ch
ti a cc sai st. Cc loi thuc cho theo y lnh phi c c tn khoa hc ln tn
thng mi, vic ghi c hai loi tn thuc bo m s nht qun trong s sch v gip
ngn nga vic gii thch sai y lnh.
- Cung cp cho bnh nhn cc thng tin bng t ri v thuc, gm c tn khoa
hc v tn thng mi. Xc nhn cc thuc m bnh nhn thc mc hoc khng nhn
ra.
3.2.3. Bin php 3: Chun ho danh mc cc t rt gn, t vit tt v cc k hiu
khng c dng trong c s y t.
- C s y t cn phi c quy nh v danh mc cc t c vit tt hoc rt gn.
Quy nh ny cn c thng tin ti mi ngi hnh ngh v phi c dn ti nhng
ni quy nh (trong bnh n hoc ni lm my tnh ca phng hnh chnh khoa).
- In danh mc l hoc cnh di ca cc t y lnh v/ hoc phiu theo di.
- Kim tra, gim st bo m cc quy nh c mi ngi hnh ngh tun th.
3.2.4. Bin php 4: Tr kt qu xt nghim ng thi gian v thng bo kp thi cc
kt qu xt nghim quan trng
- Bnh vin cn c quy nh v thi gian tr kt qu xt nghim v quy nh v
vic thng bo, tip nhn cc kt qu v gi tr xt nghim quan trng.
- Cc kt qu xt nghim bt thng quan trng c khoa xt nghim nh gi
v thng bo cho khoa hoc trc tip cho ngi ch nh xt nghim bit. Nu ngi
chu trch nhim khng c mt trong thi gian lm vic, cn c c ch bo co cc
thng tin quan trng cho nhn vin thng trc.
4. MT S TNH HUNG
V d 1: iu dng vin khoa phu thut nhn mu ti Ngn hng mu cho bnh
nhn Nguyn th Lan.Vo thi im , c hai bch mu ca hai khoa khc nhau,
nhng u cng tn Lan. Nhn vin ngn hng mu a nhm bch mu ca BN
Lan khoa khc. iu dng vin nhn mu v v bc s th phn ng cho thy hi
c ngng t nhng cho l khng vn g v cho truyn. Phn ng truyn mu xy ra
v bnh nhn t vong.
24

V d 2: Mt bc s trc cp cu ang chun b v th c yu cu khm bnh

cho bnh nhn cui cng trong ngy . Bnh nhn 18 tui, theo ngi nh ngh l ung
Paracetamol qu liu v thy l5 vin thuc ht. Bnh nhn ang c iu tr tm l v
khng nh ch ung vi vin cch nhp vin 10 gi. Bc s gii thch khng cn ra d
dy v ch nh lm xt nghim kim tra Paracetamol v Salicylate. Xt nghim vin
bo qua in thoi l salicylate m tnh; khi c kt qu xt nghim Paracetamol, k
thut vin c 2 ri ngng mt cht tip tc c 1,3 . iu dng nghe qua in
thoi v ghi l 2.13; bc s nhn kt qu v thy thp hn mc bnh thng nn
khng x tr g. Kt qu tht s l 213. Hai ngy sau BN b suy gan v t vong 10
ngy sau ./.

25

CU HI LNG GI
A. CHN CM T THCH HP IN VO CH TRNG
Cu 1. Qun L Thng Tin bao gm (1)., lu tr, trch xut, (2) ,
chuyn ti, kim sot, phn phi, v s dng (3)hc thng tin, c trong
(4).v vi bn ngoi, theo ng lut php v cc qui nh
Cu 2. Xy dng v khuyn khch h thng bo co khng khin trch, khuyn khch
nhn vin bo co (1) ., s ngng hot ng, hoc cn-s-c. C th s
dng nhng t nh (2).hoc s ngng hot ng thay v (3).. v (4)
.. thay v khin trch.
B. CHN MT HOC NHIU CU TR LI NG NHT
Cu 3. Qun l tt thng tin i hi:
A. Khuyn khch trao i v hp tc gia bc s v iu dng hoc cc nhn vin
chm sc khc.
B. Thc hin ng vn ho theo th bc khi trao i
C. Xy dng v khuyn khch h thng bo co s c ch ng
D. A v C
Cu 4. Nhng yu cu ca phu thut chnh xc ngi bnh
A. Ngi bnh chnh xc
B. Phng php chnh xc
C. V tr th thut chnh xc
D. Thi gian chnh xc
E. A, B v C
Cu 5: Ra y lnh ming l
A. Khng khuyn khch
B. Lun cn thit
C. Cn khuyn khch cng vic nhanh hn
D. A v B
Cu 6. Khi nhn y lnh ming, cn phi:
A. Nhn vin nhn lnh ming phi vit ra v c li ng nguyn vn cho ngi
bc s ra lnh nghe.
B. Ngi bc s ra y lnh phi xc nhn bng ming rng lnh l chnh xc
C. Nhn vin nhn lnh ming vit li y lnh ming v thc hin ngay
D. A v B
Cu 7. Nhng t rt gn dng ghi trn h s bnh n cn c ghi trn danh mc
cc t rt gn v k hiu khng chnh thc
A. Sai
B. ng
26

Cu 8. V s v din tin trao thng tin v ghi nhn nhng im sai st

Cu 9. Cc ni dung cn thit ci tin vic trao i thng tin ca nhn vin
Cu 10. Cc nguyn tc chung trong xc dnh ngi bnh
P N
Cu 1: 1: Thu thp; 2: Phn tch;

3: D liu;

4: Ni b c s

Cu 2: 1: S c;

3: Li;

4: Trch nhim

2: Tai nn;

Cu 3: D
Cu 4: E
Cu 5: A
Cu 6: D
Cu 7: B

27

Bi 3
PHNG NGA SAI ST TRONG S DNG THUC
MC TIU
Sau hc bi ny hc vin c kh nng:
1. Hiu c v sai st trong s dng thuc.
2. Bit c cc nguyn tc phng nga sai st, s c y khoa trong s dng thuc.
3. C th p dng c cc bin php phng nga sai st, s c y khoa trong
s dng thuc.
NI DUNG
T VN
Mc tiu ca iu tr l vic t c hiu qu iu tr cao nht v ri ro t nht
ci thin cht lng cuc sng ca ngi bnh. C nhng ri ro vn c, c c
bit v cha bit, lin quan n vic dng thuc (bao gm thuc k n hoc khng k
n) v cc thit b h tr dng thuc. Cc s c, ri ro bao gm phn ng c hi c
tc dng ph (ADR) v sai st trong s dng thuc [9].
Sai st trong s dng thuc l nhng sai st c th phng trnh c thng qua
h thng kim sot hiu qu lin quan n dc s, bc s, iu dng, nhn vin y t,
ngi bnh, v nhng ngi khc trong cc thit lp t chc cng nh cc c quan
qun l v cc ngnh cng nghip dc phm. Nhng sai st ny c th gy ra tht bi
trong iu tr v phn ng c hi ca thuc hoc gy ra lng ph cc ngun lc [6].
Theo c tnh ca vin nghin cu dc phm M, mi nm c khong t
44.000 n 98.000 ngi M cht do sai st lin quan n thuc v rt nhiu ca t
vong c nguyn nhn do dng sai thuc hoc lin quan n cc s c bt li ca
thuc [11]. S dng thuc sai liu cng l mt nguyn nhn dn n cc s c bt li
ca thuc, theo mt nghin cu trn 36 trung tm chm sc sc kho ban u M, c
5 liu thuc th c xp x 1 liu c ch nh khng ng, v c ti 7% tim tng
nguy c gp s c bt li ca thuc [5]. Sai st trong dng thuc c th xy ra trong
tt c cc hot ng: K n, cp pht, s dng thuc v khng tun th iu tr ca
ngi bnh [8].
1. GII THCH THUT NG
1.1. Phn loi sai st trong s dng thuc giai on[4]
- Mt sai st trong s dng thuc c nh ngha l mt mt thuc c s
dng khc vi y lnh trong trn h s bnh n ca ngi bnh. Sai st ny bao gm
bt k sai st no xy ra trong qu trnh k n, cp pht, s dng thuc, bt k sai st
c dn n kt qu bt li hay khng.
- Sai st trong k n (Prescribing error): La chn thuc khng chnh xc (da
vo ch nh, chng ch nh, tin s d ng thuc, cc thuc c s dng v cc
yu t khc), l cc sai st v liu dng, ng dng, dng bo ch, s lng, nng
thuc, hng dn s dng ca thuc trong n hay thm quyn k n ca bc s, n
thuc hoc cc ch vit tt khng c c dn n dng sai thuc hoc sai ngi
bnh.
28

- Sai st trong cp pht thuc (Deteriorated drug error): Cp pht cc thuc ht

hn hoc cht lng khng m bo cho ngi bnh.
- Sai st trong gim st thuc (Monitoring error): Tht bi trong vic k n theo
phc iu tr cho ph hp vi chn on hay tht bi trong nh gi ngi bnh
thng qua cc d liu lm sng hoc cc xt nghim ph hp.
1.2. Phn loi sai st trong s dng thuc theo bin c [4]
- Dng thuc khng c k trong n (Unauthorized drug error): Cho ngi bnh
dng thuc khng c k trong n/bnh n.
- Sai v thi im dng thuc (Wrong time error): Dng thuc khng ng theo
thi gian quy nh ca thuc.
- Sai liu (Improper dose error): Cho ngi bnh s dng thuc vi liu lng ln
hn hoc t hn theo yu cu ca ngi k n hoc cho ngi bnh dng liu b trng
lp.
- Sai dng thuc (Wrong dosage-form error): Cho ngi bnh dng thuc khc
dng bo ch theo yu cu ca ngi k n
- Sai st trong pha ch thuc (Wrong drug preparation error): Thuc c pha ch
khng ng hoc thao tc khng ng trc khi s dng.
- Sai k thut trong thc hin thuc (Wrong administrate technique error): Sai quy
trnh hoc k thut trong s dng thuc.
- Sai st trong tun th iu tr (Compliance error): Ngi bnh khng hp tc v
khng tun th dng thuc theo quy nh.
1.3. Phn loi cc sai st trong s dng thuc theo mc nghim trng [10]
Cha gy sai
st

A S c c kh nng gy sai st.

B Sai st xy ra nhng khng nh hng ti ngi bnh.

Sai st xy ra nh hng ti ngi bnh nhng khng gy tn
Sai st,
C
hi.
khng gy
Sai st xy ra nh hng ti ngi bnh, yu cu gim st v
tn hi
D bo co kt qu c tn hi n ngi bnh khng hoc c bin
php can thip lm gim tn hi.
Sai st xy ra gy tn hi tm thi n ngi bnh, yu cu c can
E
thip.
Sai st xy ra gy tn hi tm thi n ngi bnh, yu cu
Sai st, gy F nm vin hoc ko di thi gian nm vin.
tn hi
G Sai st xy ra gy tn hi vnh vin n ngi bnh.
Sai st xy ra, yu cu tin hnh cc can thip cn thit duy
H
tr cuc sng ca ngi bnh.
Sai st dn
n t
I Sai st xy ra gy t vong.
vong

29

2. CC YU T LIN QUAN
Cc yu t
1. Thng tin v ngi bnh
(VD: Tn, tui, gii tnh, chn on,
c thai khng, d ng, cn nng,
chiu cao, cc xt nghim lm,
kt qu iu tr cc ln trc, cc
thng s chc nng sng nh mch,
nhit , huyt p, kh nng chi tr,
ngi bnh c BHYT hay khng
c)
Thng tin cn thit v BN cn c
sn v d dng tra cu khi k n,
cp pht v gim st s dng thuc
2. Thng tin thuc
Liu ti a, dng thuc, ng
dng, ch khi s dng, cnh bo
c bit, tng tc thuc
Cc thng tin thuc c bit cn
thit trong k n, cp pht, qun l
s dng thuc
3. Trao i thng tin
Trao i thng tin ci m gia bc
s, dc s v iu dng/n h
sinh
Cch thc trao i thng tin thuc
v s dng thuc l tiu chun ho
v t ng ho gim thiu cc sai
st trong s dng thuc

Sai st c th xy ra
- Tht bi trong hiu chnh liu cho ngi
bnh suy gan, suy thn
- Khng bit tin s d ng ca ngi bnh
- Ch nh cc thuc cm ch nh cho ph
n c thai
- Tht bi trong iu tr thuc nhm opioids
cho ngi bnh suy h hp
- Nhm ngi bnh
- Ngi bnh khng c kh nng chi tr chi
ph trong iu tr
- Cn nng ca ngi bnh khng ph hp
vi liu
- Khng thu thp y thng tin v cc
thuc ang s dng thuc ca ngi bnh
- Khng c y thng tin thuc dn n
k sai liu hoc sai ng dng thuc.
- Cn b y t khng gim st cht ch cc
thuc mi hoc cc thuc cn lu c
bit
- Khng bit hoc b qua cc tng tc c
hi ca thuc
- Hi khng r rng hoc yu cu thuc
khng r rng
- n thuc vit khng r rng
- Thng tin v thuc c yu cu khng
khng y : Thiu liu dng, hm
lng, ng dng hoc tng liu thuc
k n cho ngi bnh ngoi tr.
- Ch vit tt khng r rng (g v mg)
- Nghe khng r tn thuc hoc tn ngi
bnh

4. Tn thuc, nhn thuc v dng - Cc thuc nhn ging nhau, tn gi ging

ng gi
nhau, ng gi ging nhau d b nhm ln.
Nhn thuc r rng gip xc nh - Cc nhn thuc kh hiu hoc khng r
tn thuc, hm lng trn tt c cc rng
- Thuc hoc bm thuc khng c nhn
dng bao gi.
- Dch truyn khng c nhn hoc dung
dch pha truyn khng ghi r thnh phn
Thng tin quan trng trn nhn thuc b
Nhn thuc r rng, d c nhm
gim thiu nhm ln vi cc thuc che khut
nhn ging nhau v ng gi ging - Cp pht s lng ln nhng khng ghi
r tn BN
nhau.
30

- Thuc khng co nhn

5. Tiu chun ho bo qun, tn - Nhiu dung dch tim truyn tnh mch
tr thuc
pha sai nng
Bo qun thuc, cp pht thuc, pha - iu dng chun b dung dch tim
truyn
ch thuc, nng thuc.
- S dng dung dch pha thuc khng ng
Dung dch truyn tnh mch, nng - La chn thuc khng ng do li bo
thuc v thi gian truyn cn qun ti kho thuc v hp thuc ca BN
c chun ho.
- Cc ho cht c, bc hi cng nhau
Thuc c cp pht n ngi b nh hng
- Sai thi im dng thuc
bnh an ton v kp thi.
- S dng thuc khng kp thi do yu cu
thuc chm
6. Thit b h tr dng thuc

- Bm tim in b li
VD: Dy truyn, bm tim, thit b - Khng kim sot c tc truyn dch
cy thuc vo c th, bm tim pha do li ca dy truyn dn n sai liu
thuc, dng c theo di ng thuc
- Cc thit b truyn dch khng tng
huyt.
thch vi nhau dn n sai st trong dng
Cc thit b h tr dung thuc t thuc (kim truyn v dy truyn)
chun thng qua qu trnh mua - Cung cp thit b h tr dng thuc
sm, bo qun v s dng s gim khng y (thiu bm tim in)
thiu c cc nguy c do ngi s
dng.
7. Cc yu t mi trng lm vic - Thuc sp xp ln xn do thiu khng
nh hng n nhn vin y t.
gian hoc do mi trng lm vic khng
gn gng, hoc do qu nhiu thuc v
V d: ng nghip, sc kho, cch
khng th sp xp c.
t chc n v, nh sng, ting n,
qu ti trong cng vic, lch lm - Hiu sai n t hng do qu n v mt
tp trung
vic
- Sai st trong chun b thuc do thiu nh
Vic s dng thuc bao gm k n,
sng v thiu t ng thuc
cp pht thuc, thc hin thuc v - Nhn s khng dn n qu ti trong
gim st s dng thuc cn c
cng vic v cc th tc hnh chnh
tin hnh trong mt mi trng lm - Cn b y t mt mi gy sai st v km
vic thch hp c nh sng,
hiu qu trong cng vic.
- Ngh ngi khng dn n qu ti v
tinh thn v tng kh nng gy sai st
- Thiu k hoch d phng v nhn s cho
ngh m v ngh l
- Khng chun b nhn lc cho cc dch v
k thut mi
8. Nng lc v o to ca cn b - Thiu hiu bit v cc quy tc trong thc
y t
hnh v mi trng lm vic dn n
chm tr v sai st gy ra hiu lm gia
(V d: Chuyn khoa o to, bng
iu dng v dc s.
cp, nng lc chuyn mn, k nng,
31

cc hot ng chuyn mn tham - Thiu hiu bit v nh gi v theo di

gia, cc bng cp khc)
ngi bnh dn n sai st hoc s dng
thuc khng ng.
- Nhn vin mi, thiu kinh nghim c th
Cn b y t c o to y ,
gy cc sai st do qu ti v nhim v v
ng chuyn ngnh v c nh
cha thnh tho cc quy trnh lm vic
gi nng lc chuyn mn v k nng - Sai st trong s dng thuc lin quan n
hng nm c lin quan n vic s
phn cng cng vic khng ph hp vi
dng thuc an ton, hp l
chuyn ngnh, nh hng hoc phn
cng cho ngi mi, cha quen vi cng
Cn b y t cn c o to lin
vic
tc v phng nga cc sai st c
lin quan n s dng thuc v an - Thiu thng tin v thuc mi (liu dng,
cch pha thuc, ch nh, tc dng ph,
ton trong s dng thuc trnh
tng tc thuc) gy sai st.
cc nguy c tim n nu xy ra cc
- Sai st do khng bo co hu qu cc sai
bin c bt li.
st xy ra phng trnh
9. o to ngi bnh
(V d: Bng thng tin thuc, cch
s dng cc thuc, hng dn dng
thuc khi ra vin, cch trnh cc sai
st khi dng thuc ).
Ngi bnh l mt i tc tch cc
quan trng trong vic t chm sc
thng qua t vn v thuc v cch
phng trnh cc sai st trong s
dng thuc.

- Ngi bnh khng thoi mi khi hi nhn

vin y t v cc thuc h ang dng v
cch dng thuc.
- Ngi bnh c th khng hiu thng tin
cc thuc h ang dng do khng hiu cc
thut ng v thuc hay do ro cn v ngn
ng
- Thng tin thuc t cc t hng dn s
dng khng y hoc ngi bnh
khng c k dn n khng hiu cch
dung thuc
- Ngi bnh c th khng nh cch s
dng cc thuc ang dng, dn n gy ra
sai st. Vn tng ln khi bc s k qu
nhiu thuc trong cng 1 n.
Ngi bnh thiu thng tin v nguyn nhn
gy ra sai st v cch phng trnh.

10. Quy trnh qun l cht lng - Thiu lnh o v chi ph h tr cho vic
v ri ro
an ton trong s dng thuc
(V d: Vn ho, lnh o, bo co - Tm l xu h, li, s trch nhim,
l ro cn cho cc bo co sai st trong h
sai st, cc chin lc an ton, )
thng.
Hi ng qun tr, cc nh lnh o - Vn ho gi b mt v li ngn cn
v cc nh qun l phi xy dng v vic thng bo cc sai st cho ngi bnh
h tr h thng khng trng pht v ngi nh ngi bnh
nhm gim cc sai st.
- T l cc sai st thng qua cc bo co
Cn b y t c khuyn khch pht khng chnh xc.
hin v bo co sai st. Mt nhm - Gii php phng trnh sai st thiu tnh
gm cc thnh vin thuc nhiu lnh ng b ca tp th nn thiu hiu qu.
vc thng xuyn phn tch cc sai - Thiu kin thc chuyn mn mt cch h
32

st xy ra nhm c cu li t
chc h tr tt nht cho s an
ton.

thng dn n khng gii quyt sai st

mt cch trit .

3. CC TNH HUNG SAI ST

3.1. Sai st lin quan n k n thuc
n thuc l cn c hp php bn thuc, cp pht thuc, pha ch thuc theo
n v s dng thuc. Rt nhiu sai st lin quan n k n khng c pht hin v
bo co. Tuy nhin, cc bng chng nghin cu n nay cho thy, sai st thuc trong
k n l vn thc t rt quan trng. Trong mt phn tch v nh hng ca cc sai
st y t vi i tng tr em xc nh cc sai st chim 24,5% cc can thip y t
c ghi nhn, sai st ph bin nht thuc v cc sai st trong k n chim 68,3%
[6]. Cc sai st trong k n nu khng c pht hin c th gy ra cc sai st trong
thc hnh. Tuy nhin, dc s v iu dng c th tham gia pht hin ti 70% cc sai
st thuc trong n thuc [6].
i vi n thuc ngoi tr, cc thng tin trong n cn ghi r: H tn y v
a ch lin lc ca ngi bnh, cc thng tin khc v ngi bnh: Tui, gii tnh, cn
nng, d ng thuc, tn thuc (nn l tn generic), nu l tn bit dc, nn ghi thm
tn hot cht, hm lng/ nng ca thuc, dng bo ch thuc, s lng thuc (ghi
r s lng s dng theo n v, khng nn ghi theo n v ng gi), hng dn
dng thuc, bao gm cch dng, ng dng, liu dng, (ghi r: Dng theo ch dn
ca bc s). i vi ngi bnh ni tr, bc s cn khai thc y thng tin bao
gm: Chc nng gan, thn, tui, cn nng tnh liu dng thuc hoc cc chng ch
nh cho ngi bnh [1].
Mt s sai st thng gp trong k n thuc
-

Thiu thng tin ngi bnh: Tn, tui (thng vi tr em nh hn 3 tui), cn nng
Ghi sai tn thuc (cc thuc tn ging nhau)
Ghi thiu hm lng thuc
Ghi thiu hng dn s dng thuc
K cc thuc c tng tc mc nguy him
Ch vit qu kh c, gy nhm ln khi cp pht v thc hin thuc (v d:
500mg thay v 0,5g, 125mcg thay v 0,125mg)
Vit tt trong n, gy nhm ln (VD: g thay v mcg, U thay v Unit)
K n bng ming

3.2. Sai st trong giai on cp pht thuc

Sai st trong giai on cp pht thuc c th xy ra trong bt c giai on no k
t lc tip nhn n thuc cho ti khi thuc c a n ngi bnh. iu ny
thng xy ra do cc thuc c tn hoc hnh thc tng t nhau.
V d: - Amilorid v amlodipin, Lasix (furosemid) v Losec (omeprazol).
3
Cisplatin v Carboplatin
4
Ephedrin v Epinephrine
5
Cc ch phm Insulin: Humalog v Humulin, Novolog v Novolin
6
Daunorubicin v Doxorubicin
Mt s sai st thng gp trong cp pht thuc [7]
33

- Khng cho ngi bnh dng thuc k trong n

- Cho ngi bnh dng thuc khng c bc s k n
3.3. Sai st trong thc hnh s dng thuc
Sai st trong thc hnh s dng thuc xy ra trong qu trnh dng thuc ca ngi
bnh, c th do nhn vin y t hoc do ngi bnh khng tun th.
Mt s sai st trong thc hnh s dng thuc[7]
Dng thuc sai ngi bnh
- Dng sai thuc hay sai dch truyn
- Dng thuc sai liu hoc sai hm lng
- Dng sai dng thuc, v d, dng thuc nh mt dng dung dch thay v dng
m tra mt
- Sai ng dng thuc
- Sai tc dng thuc (V d: Trong truyn dch)
- Sai thi gian hay khong cch dng thuc
- Sai thi gian iu tr
- Sai st trong pha ch liu thuc (V d: Sai st trong khi pha long thuc hay
khng lc thuc dng hn dch khi s dng)
- Sai k thut dng thuc cho ngi bnh (V d: Sai st trong k thut tra thuc
nh mt)
- Dng thuc cho ngi bnh c tin s d ng trc .
3.4. Nguyn nhn dn n sai st trong dng thuc
Mt s vn hay gp lin quan n sai st trong s dng thuc c th gii
quyt bao gm [7]:
1. S qu ti v mt mi trong cng vic ca cn b y t
2. Cn b y t thiu kinh nghim lm vic hoc khng c o to y , ng
chuyn ngnh
3. Trao i thng tin khng r rng gia cc cn b y t (VD: Ch vit xu, k
n bng ming)
4. Cc yu t v mi trng nh thiu nh sng, qu nhiu ting n hay thng
xuyn b gin on cng vic
5. S lng thuc dng cho mt ngi bnh nhiu
6. Vic k n, cp pht hay thc hin thuc phc tp
7. S dng nhiu chng loi thuc v nhiu dng dng (VD thuc tim) gy ra
nhiu sai st lin quan n thuc
8. Nhm ln v danh php, quy cch ng gi hay nhn thuc
9. Thiu cc chnh sch v quy trnh qun l thuc hiu qu
4. GII PHP
Mt s cch ngn chn cc sai st trong dng thuc, c bit trong bnh vin
bao gm:
- Gii php mang tnh h thng
- Xy dng cc gii php vi cc i tng c lin quan: Bc s, dc s, iu dng.
- Gim st v qun l sai st
34

4.1. Gii php mang tnh h thng [9]

4.1.1. Cung cp y chnh xc thng tin ngi bnh
- Tr kt qu xt nghim qua mng.
- Thng bo v tin s d ng ca ngi bnh cho bc s/dc s trc khi cp pht
v gim st s dng thuc.
- Lit k cc phn ng d ng v chn on trn y lnh hc n thuc.
- eo vng eo tay nh du ngi bnh c tin s d ng.
- Lun mang theo y lnh khi gam st s dng thuc, t vn cho ngi bnh trc khi
cp pht thuc.
- Yu cu theo di k ngi bnh c nguy c cao: Bo ph, hen, ngng th khi ng
khi s dng thuc nhm opioids.
4.1.2. Cung cp y thng tin thuc cho bc s, iu dng
- Cp nht kp thi thng tin thuc
- C dc s t vn cho ngi bnh v thuc
- Cung cp thng tin di dng biu , quy trnh, hng dn, checklist cho cc thuc
c cnh bo cao
- Lit k liu ti a ca cc thuc c cnh bo cao, thng tin di dng phiu yu cu
hoc cnh bo thng qua h thng mng ca bnh vin
- C dc s xem xt cc ngh s dng cc thuc cn yu cu trc khi s dng
4.1.3. m bo trao i thng tin gia bc s - dc s - iu dng y , chnh xc
- S dng h thng k n in t v h thng mng bnh vin.
- S dng mu yu cu thuc chun v y thng tin.
- Hn ch yu cu thuc qua in thoi, c bit cc thuc iu tr ung th (Tr
trng hp khn cp).
- c li cc yu cu v thuc m bo thng tin y v chnh xc.
- Xy dng quy trnh, thng nht tng bc tin hnh khi yu cu thuc.
- Gi tt c cc yu cu thuc cho khoa Dc, k c cc thuc c sn hay cc thuc
khng c sn.
4.1.4. m bo tn thuc, nhn thuc v dng ng gi r rng, ng quy cch
-

Lu cc thuc nhn ging nhau hoc tn thng mi ging nhau

Cp pht cho khoa lm sng thuc c tn thuc, hm lng.
Dn nhn cho tt c cc thuc, lm ni bt tn thuc v hm lng
Trong khoa lm sng, cc thuc ung c bo qun trong hp n tn khi cp pht
cho ngi bnh.
- Sp xp cc thuc nhn ging nhau ti cc ni ring bit trnh nhm ln
- S dng cc nhn cnh bo cho nhn vin y t v cc thuc c ch dn c bit v
bo qun hoc an ton
- m bo cc thuc u d c v d hiu
4.1.5. Bo qun, tn tr thuc t tiu chun GSP: D thy, d ly, d tm, trnh
nhm ln, h hng
-

Chun ho nng ca Insulin, Heparin, Morphin.

S dng cc dung dch tim truyn pha sn.
Hn ch vic iu dng pha dung dch tim truyn tnh mch trong trng hp cp cu.
Xy dng quy nh lnh thuc hng ngy, thuc cp cu cho nhn vin y t.
35

- Bo qun cht cc thuc cnh bo cao, cc thuc dng cho ngi bnh c bit, thuc
cn qun l theo quy nh.
- Khng cc dung dch in gii m c ti cc hp thuc c nhn ca ngi bnh.
- Cp pht thuc cho ngi bnh theo liu dng, khng cp pht theo tng liu iu tr.
- Loi b cc thuc s dng khng lin tc ra khi cc thit b kp thi.
- Khng vay mn thuc ca ngi bnh trong qu trnh iu tr.
- Thit lp t thuc cp cu ti cc khoa lm sng.
4.1.6. m bo la chn cc thit b h tr dng thuc ph hp vi bnh vin v
trnh chuyn mn
- Kim tra k cc thit b trc khi mua v s dng.
- Hn ch s dng nhiu loi bm tim nhm s chuyn nghip ca nhn vin y t
trong thc hnh.
- Cm s dng cc thit b truyn dch khng kim sot c tc truyn dch.
- o to k cho nhn vin y t v cc thit b mi v k thut mi trc khi s dng.
- Kim tra hai ln (double- check) khi truyn dch bao gm: Dch truyn, cc thit b
h tr, tnh trng ngi bnh trc khi truyn cc thuc cnh bo cao.
4.1.7. m bo mi trng lm vic nh hng n nhn vin y t
- m bo y nh sng khng gian, trong kho thuc bao gm t ng thuc v h
thng cp pht thuc t ng.
- Xy dng mi trng lm vic khng lm mt tp trung cho vic yu cu/t n
hng thuc.
- B tr cc khu vc thuc tim truyn, thuc ung, thuc pha ch ring bit, trnh
ting n, i li nhiu v cc tc ng gy mt tp trung.
- Trang b t lnh c din tch bo qun thuc.
- C k hoch v nhn s thay th cho cn b y t khi ngh m, ngh php v ngh l.
- Quy nh r rng v thi gian ngh gii lao v ngh n tra, n ti cho cn b y t.
- Qun l v gim st thi gian lm vic ca cn b y t, m bo c ngh ngi y
sau ca trc v khng lm vic qu 12h mi ngy.
- Hn ch ti a vic s dng nhn vin y t tm thi.
- Thng bo cho tt c cn b y t c lin quan v k hoch v thc hin dch v k
thut mi, bao gm c chi ph cn thit b sung m bo s an ton cho ngi bnh.
4.1.8. o to v nh gi thng xuyn nng ca cn b y t, b tr cng vic ph hp
- B tr cng vic ng theo chuyn ngnh o to, nh k nh gi.
- B tr cng vic hp l gim qu ti trong cng vic.
- Yu cu cc iu dng mi phi thc tp ti khoa Dc lm quen vi cng vic
cp pht thuc.
- Yu cu cc dc s mi phi thc tp ti khoa lm sng lm quen vi quy trnh
s dng thuc.
- Cung cp thng tin thuc mi trc khi a vo s dng.
- Khoa Dc dn nhn cnh bo cho iu dng cc thng tin cn lu vi cc thuc
cnh bo cao
- B tr nhn vin y t c o to v sai st trong s dng thuc trong n v
nhm ngn chn cc sai st xy ra.
- M t v nh gi cng vic c th v vi trch nhim i vi ngi bnh.
36

- Cung cp cho cn b y t nhng h tr cn thit v thi gian tham d cc kho

hc trong v ngoi nc v phng nga sai st trong s dng thuc.
4.1.9. T vn ngi bnh v thng tin thuc v tun th iu tr
- T vn ngi bnh cch ch ng trong vic tm hiu v xc nh ng trc khi
nhn thuc hay s dng thuc.
- Cung cp thng tin cho ngi bnh hoc gia nh ngi bnh v tn thuc (bao gm
tn bit dc v hot cht) cch s dng, mc ch iu tr, liu dng v cc phn
ng ph nghim trng.
- Hi kin dc s v cch s dng thuc nu ngi bnh dng trn 5 loi thuc.
- Khuyn khch ngi bnh hi v cc thuc iu tr.
- Tr li y cc cu hi ca ngi bnh v thuc (nu c) trc khi iu tr.
- Cung cp cho ngi bnh thng tin v cc thuc cnh bo cao k trong n thuc khi
xut vin.
- Cung cp cho ngi bnh s in thoi v ngi lin lc khi cn hi thng tin v
thuc sau khi xut vin.
- Khuyn khch ngi bnh gi tt c thng tin v n thuc dng, cc thuc khng
k n, thuc ng dc, vitamin v a cho nhn vin y t khi nhp vin hoc iu
tr ti nh.
4.1.10. Xy dng quy trnh qun l cht lng v ri ro ti n v
- Cng b vn an ton cho ngi bnh l nhim v ca n v.
- o to cho cn b qun l bc trung nh gi hiu qu v nng lc v kh nng
gii quyt cc vn phc tp.
- Thay i cch ngh li khi xy ra sai st trong s dng thuc, khi cc li khng
d on hoc khng o m c.
- Thc y vic bo co thng xuyn v duy tr cc sai st t cc khoa phng iu tr.
- Thng tin tt c cc sai st cho ngi bnh.
- nh k tho lun nhm v cc sai st xy ra v cch phng trnh.
- Xy dng nhm a ngnh thng xuyn phn tch, nh gi cc sai st v cc d liu
v an ton ngi bnh thit lp h thng m bo an ton cho ngi bnh.
- Mi i din hi ng ngi bnh tham gia tho lun v vn an ton, khuyn
khch cng tham gia.
- Ph bin rng ri thng tin v cc gii php phng nga sai st.
- S dng cng ngh m ho bnh nhn trong iu tr.
4.2. Gii php vi cc i tng c lin quan
4.2.1. i vi bc s [4]
- La chn phc iu tr ph hp, tham kho kin dc s v t vn vi cc
bc s chuyn ngnh su.
- nh gi tng trng ca ngi bnh v xem xt tt c cc thuc ang iu tr
xc nh tng tc thuc. Theo di cc triu chng lm sng v cc kt qu xt
nghim cn thit nh gi v ti u ha iu tr v kh nng p ng vi iu tr
bng thuc ca ngi bnh.
- Bc s cn bit v h thng qun l thuc ti bnh vin, bao gm: Danh mc
thuc bnh vin, quy trnh iu tra s dng thuc, Hi ng c thm quyn quyt nh
37

la chn thuc, quy trnh thng tin thuc mi, cc quy nh v qun l thuc v quy
nh k n thuc.
- n thuc cn ghi y cc thng tin: H tn ngi bnh, tn thuc (tn gc
v tn thng mi), nng /hm lng, ng dng, dng dng, liu lng, s lng,
tn sut s dng, tn bc s k n.
- n thuc c ghi r rng, d c, d hiu:
- Khng s dng ch vit tt .
- Ghi cch s dng c th cho mi loi thuc trong n.
- Ghi r s lng cn s dng ng theo n v o lng (mg, ml), khng
nn ghi theo n v ng gi (l, hp), ngoi tr cc thuc dng phi hp.
- K n tn thuc theo tn gc, trnh: K thuc tn a phng (thuc b
lang), tn ha hc, vit tt tn thuc.
- Lun s dng mt s 0 trc n v nh hn 1 (v d: 0,5 ml) . Vi n
v ln hn 1, khng c thm s 0 vo sau (v d , 5,0 ml ).
- Ghi r n v tnh, trnh nhm ln (V d: 10 units Unsulin thay v 10U,
c th nhm l 100).
- n thuc v ch k bc s phi r rng. Nu c th nn s dng my tnh
hoc k n thuc qua h thng my tnh.
- Vi cc y lnh hoc k n thuc bng ming, bc s chc chn ngi thc
hin hiu ng n thuc bng cch c li n thuc cho bc s.
- Hn ch k n thuc tim.
- Gii thch vi ngi bnh hoc ngi nh v cc lu v tc dng ph ca thuc.
- Theo di ngi bnh v nh k khm li.
4.2.2. i vi dc s
- Trin khai hot ng Dc lm sng ti bnh vin, c dc s tham gia gim
st iu tr bng thuc (tham gia t khi khm bnh, la chn thuc iu tr thch hp,
dng thuc, xem xt kh nng tng tc thuc, trng lp thuc, nh gi triu chng
lm sng v cc xt nghim thch hp vi ngi bnh), iu tra s dng thuc gip
s dng thuc an ton, hp l [4].
- Sn sng cung cp thng tin v thuc cho bc s v iu dng.
- Hiu r v cc quy trnh v quy nh trong cung ng thuc ti bnh vin, k c
thuc cp pht ni tr, ngoi tr v nh thuc bnh vin.
- m bo hiu r n thuc trc khi cp pht.
- Sp xp khu vc chun b thuc gn gng, sch s v trnh gin on khi chun b.
- Trc khi cp pht thuc hng ngy, cn kim tra k n thuc. m bo thc
hin ng quy trnh cp pht. i vi cc thuc cnh bo cao (thuc iu tr ung th,
thuc cp cu) cn kim tra 2 ln.

38

- Nn s dng nhn ph cnh bo cc thuc c nguy c cao v ch cch s

dng thuc. Ngn nga cc sai st lin quan n tn thuc nhn ging nhau, c
ging nhau (LASA) [9].
1. Cung cp thng tin v cc thuc LASA cho bc s, iu dng, dc s
trong bnh vin.
2. Xc nh mc ch s dng thuc trc khi cp pht thuc hay s dng thuc.
3. Ch chp nhn y lnh bng ming khi tht s cn thit, tr vi cc thuc
iu tr ung th.
4. HT&T cn xem xt cc thuc khi la chn thuc vo Danh mc thuc
bnh vin, trnh cc thuc nhn ging nhau, c ging nhau.
5. K n thng qua h thng mng, trnh nhm ln tn thuc do ch vit kh c.
6. Thay i cch nhn bit v tn cc thuc nhn ging nhau (c trong h
thng kho tng v my tnh) bng cch nh du, vit ch ci cao hn
(DAUNOrubicin v DOXOrubicin).
7. Cnh bo nguy c sai st do nhm ln thng qua h thng mng bnh vin.
8. Sp xp cc thuc LASA ti cc v tr khc nhau trong kho thuc, t thuc,
hp thuc ca ngi bnh. Dn cc nhn cnh bo cho cn b y t trn
cc l thuc.
9. ngh bo co cc trng hp sai st c bin php phng trnh kp
thi.
- m bo thuc c cp pht kp thi, m bo thi gian iu tr [3].
- Gim st cht lng v quy trnh s dng cc thuc ti t trc thuc ti cc
khoa lm sng, m bo ti u ha trong iu tr.
- Gim st cht lng v quy trnh tr thuc t cc khoa lm sng. nh gi cc
thuc khng s dng do qun liu.
- Vi cc n thuc k cho ngi bnh xut vin, t vn c th cho ngi bnh
hoc ngi nh cch s dng ca tng thuc, cc lu v cn trng khi s dng.
- Thu thp v lu tr cc d liu v sai st trong s dng thuc phng nga v
iu chnh cc hot ng v s dng thuc.
4.2.3. i vi iu dng
- Hiu r v cc quy trnh v quy nh trong cung ng thuc ti bnh vin, k c
thuc cp pht ni tr, ngoi tr [4].
- Dng thuc ng theo ch nh ca bc s iu tr.
- Chun b v ph hp cc phng tin cho ngi bnh dng thuc; khi dng
thuc qua ng tim phi chun b sn sng hp thuc cp cu v phc chng sc,
chun b ng v dung mi theo quy nh ca nh sn xut.
- Kim tra thuc (tn thuc, nng /hm lng, liu dng mt ln, s ln dng
thuc trong 24 gi, khong cch gia cc ln dng thuc, thi im dng thuc v
ng dng thuc so vi y lnh). Kim tra hn s dng v cht lng ca thuc bng
cm quan: Mu sc, mi, s nguyn vn ca vin thuc, ng hoc l thuc [2].
- Thc hi n 5 ng khi dng thuc cho ngi b nh: ng ngi bnh, ng
thuc, ng liu lng, ng ng dng, ng thi gian dng thuc.
39

- Bo m ngi bnh ung thuc ngay ti ging bnh trc s chng kin ca
iu dng vin, h sinh vin.
- Ghi hoc nh du thuc dng cho ngi bnh v thc hin cc hnh thc
cng khai thuc ph hp theo quy nh ca bnh vin.
- Theo di, pht hin cc tc dng khng mong mun ca thuc, tai bin sau
dng thuc v bo co kp thi cho bc s iu tr. in thng tin cn thit vo mu
bo co ADR v thng bo cho dc s ph trch.
- Hng dn, gii thch cho ngi bnh tun th iu tr. Gii thch cho ngi
bnh v ngi nh v tc dng v quy trnh dng thuc. Vi ngi bnh t chi iu
tr theo y lnh, bo co cho bc s iu tr.
- Phi hp gia cc bc s, dc s, iu dng vin, h sinh vin trong dng
thuc nhm tng hiu qu iu tr bng thuc v hn ch sai st trong ch nh v s
dng thuc cho ngi b nh.
4.3. Gim st v qun l sai st trong s dng thuc [4]
4.3.1. Gim st cht cc yu t c kh nng gy sai st
- Ca trc (t l sai st xy ra cao hn khi i ca).
- Nhn vin mi (thiu kinh nghim v cha c o to y ).
- Cc i tng bnh nhn: Ngi gi, tr s sinh, bnh nhn ung th.
- Bnh nhn s dng nhiu thuc (d xy ra tng tc thuc).
- i trng lm vic (nh sng, ting n, hay b gin on).
- Cn b y t qu ti v mt mi.
- Trao i thng tin gia cc cn b y t khng y , r rng.
- Dng thuc (VD: Gim st s dng thuc tim cht ch).
- Bo qun thuc khng ng.
- Tn thuc, nhn thuc, cch ng gi d gy nhm ln.
- Nhm thuc s dng nhiu.
- Ch vit tay trong bnh n hoc n thuc khng r rng.
- Hnh thc k n, yu cu thuc bng ming d gy nhm ln.
- Cc quy trnh lm vic cha hiu qu.
- Hot ng ca Hi ng thuc v iu tr (c chc nng gim st) cha hiu qu.
4.3.2. Qun l cc sai st trong s dng thuc
- m bo h tr v cung cp cho ngi bnh cc liu php khc phc khi xy ra
sai st.
-

Ghi chp v bo co ngay cc sai st khi c pht hin theo cc mu quy nh

ca tng bnh vin (mu bo co ADR, bo co cht lng thuc).
Vi mi sai st xy ra, cn thu thp cc thng tin v bo co y bng vn
bn cc ni dung, bao gm: Vn xy ra, ni xy ra, ti sao v nh th no,
cc i tng c lin quan. Thu thp v gi li cc bng chng c lin quan n
s vic (v thuc, sy lanh) tm nguyn nhn v cch phng trnh.
Lnh o bnh vin, Hi ng qun l cht lng, Trng khoa (phng) v c
nhn c lin quan bnh vin xem xt cc sai st v bin php khc phc kp thi.
Nn thng tin rng ri v nguyn nhn v cch gii quyt cc sai st xy ra.
Cc sai st thng mang tnh h thng, khng nn x l bng bin php k lut
m khuyn khch bo co c bin php phng nga.
40

Thng tin t cc bo co sai st nn c lm ti liu o to cho cn b y t

hoc lm cn c xy dng cc quy nh phng cch phng trnh sai st.
Lnh o bnh vin v cc hi ng c lin quan nh k nh gi cc sai st v
xc nh nguyn nhn gy sai st v xy dng cc gii php phng trnh (o
to, lun chuyn cn b, sa i chnh sch v quy trnh, thay th cc trang thit
b khng ph hp, ).
Bo co cc sai st ln trung tm quc gia tng hp v c chin lc phng
trnh sai st trn ton quc.
TI LIU THAM KHO

1. B y t, (2008) Quyt nh s 04/2008/Q-BYT v vic ban hnh Quy ch k n

thuc trong iu tr ngoi tr
2. B Y t, (2011) Thng t s 07/2011/TT-BYT hng dn cng tc iu dng v
chm sc ngi bnh trong bnh vin
3. B Y t, (2011) Thng t 23/2011/TT-BYT hng dn s dng thuc trong c s y t
c ging bnh.
4. American Society of Hospital Pharmacists (1993), ASHP Guidelines on Preventing
Medication Errors in Hospitals, Am J Hosp Pharm; 50:30514.
5. Barker et al (2002), "Medication Errors Observed in 36 Health Care Facilities",
Archives of Internal Medicine 162:1897-903.
6. Bates DW, Spell N et al (1997), "The costs of adverse drug events in hospitalized
patients", JAMA 1997; 277:301-34.
7. Kathleen Holloway, Terry Green, (2005), Drug and Therapeutics Committees - A
Practical Guide, World Health Organization n collaboration with Management
Sciences for Health
8. Kohn LT, Corrigan JM et al (1999), "To err is human-building a safer health
system", Washington, DC: National Academy Press.
9. Michael R. Cohen, (2010) Medication Errors, American Society of Hospital
Pharmacists, 2010.
10. National Coordinating Council for Medication Error Reporting and Prevention
(2013), NCC MERP Index for Categorizing Medication Errors.
11. Phillips DF, Christefeld N, Glynn LM (1998), "Increase in U.S. medication-error
deaths between 1983 and 1993", Lancet. 1998; 351:643-4.

41

CU HI LNG GI
Cu 1. Sai st trong s dng thuc xy ra trong:
A. K n thuc
C. Thc hnh s dng thuc

B. Cp pht thuc
D. Tt c cc hot ng trn.

Cu 2. Lit k cc loi sai st trong s dng thuc theo giai on?

Cu 3. Lit k cc loi sai st trong s dng thuc theo bin s?

Cu 4. Cc yu t h thng lin quan n sai st trong s dng thuc? La chn cu

tr li ng.
A. Lnh o bnh vin
B. Thng tin ngi bnh
C. Thng tin thuc
D. Trao i thng tin gia cc nhn vin y t
E. Tn thuc, nhn thuc v dng ng gi
F. Tiu chun ho bo qun, tn tr thuc
G. Thit b h tr dng thuc
H. Cc yu t mi trng lm vic nh hng n nhn vin y t.
I. Nng lc v o to ca cn b y t
K. o to ngi bnh
L. Quy trnh qun l cht lng v ri ro
M. C s vt cht ca bnh vin
Cu 5. Cc sai st hay gp trong k n thuc? La chn cu tr li ng.
A. Thiu thng tin ngi bnh: tn, tui (thng vi tr em nh hn 3 tui), cn
nng
B. Ghi sai tn thuc
C. Ghi thiu hm lng thuc
D. Ghi thiu hng dn s dng thuc
E. Dng sai thuc trong n
F. K cc thuc c tng tc mc nguy him
G. Dng thuc sai thi im
H. Ch vit qu kh c
I. Vit tt trong n, gy nhm ln
K. K n bng ming
Cu 6. Cc sai st hay gp trong cp pht thuc
A.Khng cho ngi bnh dng thuc k n
B.Cho ngi bnh dng sai thuc k trong n
C.Khng hng dn ngi bnh bo qun thuc
Cu 7. Cc sai st hay gp trong thc hin thuc
42

A. Dng thuc sai ngi bnh

B. Dng sai thuc hay sai dch truyn
C. Dng thuc sai liu hoc sai hm lng
D. Dng sai dng thuc, v d dng thuc nh mt dng dung dch thay v dng
m tra mt
E. Sai ng dng thuc
F. Sai tc dng thuc (V d: trong truyn dch)
G. Sai thi gian hay khong cch dng thuc
H. Sai thi gian iu tr
I. Hng dn s dng thuccho ngi bnh sai
K. Sai st trong pha ch liu thuc
L. Sai k thut dng thuc cho ngi bnh
M. Dng thuc cho ngi bnh c tin s d ng trc
N. K cc thuc c tng tc mc nguy him
Cu 8. Lit k nhng nguyn nhn dn n sai st trong dng thuc

Cu 10. Xc nh cu ng sai
TT Gii php ngn nga sai st trong s dng thuc
1

Khng k n in t

Tr xt nghim qua mng

o to, gim st kim tra trnh nng lc cn b y t

C bin pht k lut nng vi ngi gy ra sai st

Che giu cc sai st xy ra, trnh b k lut

Xy dng h thng bo co cc sai st trong s dng

thuc ti n v

C bin php khuyn khch bo co cc sai st xy ra

c k n bng ming hay qua in thoi

Khng s dng ch vit tt .

10

Ghi cch s dng c th cho mi loi thuc trong n

11

Lun s dng mt s 0 trc n v nh hn 1

12

Cung cp thng tin v cc thuc LASA cho bc s, iu

dng, dc s trong bnh vin

13

eo vng eo tay nh du ngi bnh c tin s d ng

14

Khng cn xy dng cc quy trnh trong s dng thuc

15

iu dng chu trch nhim pha thuc tim truyn tnh

mch

43

P N
Cu 1: D
Cu 2: K n, cp pht, thc hin thuc
Cu 3: Dng thuc khng c k trong n, sai v thi im dng thuc, sai liu, sai
dng thuc, sai trong pha ch thuc, sai k thut trong thc hin thuc, sai st trong
tun th iu tr.
Cu 4: A-C-E-D-B-F-I-H-G
Cu 5: B,C,D,E,F,G,H,I,K,L
Cu 6: A,B,C,D,F,H,I,K
Cu 7: A,B
Cu 8:A,B,C,D,E,F,G,H,K,L,M.
Cu 9:
-

Qu ti v mt mi,
Thiu kinh nghim lm vic hoc khng c o to y , ng chuyn ngnh,
Trao i thng tin khng r rng gia cc cn b y t,
Thiu nh sng, qu nhiu ting n hay thng xuyn b gin on cng vic,
S lng thuc dng cho mt ngi bnh nhiu,
K n, cp pht hay thc hin thuc phc tp,
Nhiu chng loi thuc v nhiu dng dng,
Nhm ln v danh php, quy cch ng gi hay nhn thuc,
Thiu cc chnh sch v quy trnh qun l thuc hiu qu,

Cu 10:
1S, 2, 3, 4S, 5S, 6, 7, 8S, 9, 10, 11, 12, 13, 14S, 15S

44

Bi 4
PHNG NGA SAI ST, S C Y KHOA TRONG PHU THUT
MC TIU
1.
2.
3.
4.

Sau khi hc bi ny hc vin c kh nng:

Trnh by c khi nim sai st, s c y khoa trong phu thut v mc nh
hng ca s c y khoa trong phu thut
M t c vai tr ca nhn vin y t trong phng nga sai st, s c y khoa
trong phu thut.
Thc hin c cc bin php phng nga nhm gim thiu sai st, s c
trong phu thut
p dng Bng kim an ton Phu thut ca WHO v hng dn p dng

NI DUNG
1. BNG CHNG NGHIN CU
Phu thut l mt k thut y t c thc hin vi mc ch chn on
bnh, iu tr, chnh hnh, ghp tng, gim au c tin hnh ph bin trong chm
sc ngi bnh. Tuy nhin trong qu trnh tin hnh phu thut, sai st v s c c th
xy ra. Mi bin c v tai bin c th xy ngay trc cuc m bt u (phn ng thuc
m, t) cho n thi gian v sau, thm ch hng nm sau khi ngi bnh ra vin
( qun trong c th ngi bnh), gy nh hng sc khe, c v th lc v tm l
lu di. Hu qu khng ch lm nh hng n cht lng cuc m, cn lm tng thi
gian iu tr v nm vin, tng chi ph iu tr, ngi bnh gim thu nhp, tng t l
mc v t vong, nhng au n m ngi bnh phi gnh chu cng nh vn kin
co v php lut .
Theo bo co ca T chc Y t th gii WHO, mi nm trn ton th gii c
chng c trn 230 triu ca phu thut c thc hin tng ng (1 : 25 ngi), gp
2 ln s tr c sinh ra. Bin chng xy ra gy nguy him n tnh mng ti 7 triu
trng hp (khong 16%), trong gn 1 triu trng hp t vong lin quan n an
ton phu thut (gn 10%) cc bin chng cht ngi xy ra ti cc phng m ln. C
150 ngi bnh nhp vin, c 1 trng hp t vong do s c y khoa v 2/3 s c xy
ra trong bnh vin lin quan n phu thut. S c y khoa tc ng n 1/10 bnh
nhn trn ton th gii.
Theo nhng bo co gn y cho tht t l s c (Adverse events) lin quan n
phu thut ch yu xy ra cc nc km v ang pht trin chim khong 18%. Cc
bnh l cn can thip phu thut ngy cng tng do: Bnh l tim mch tng, tng tai
nn thng tch v nhiu ngi bnh chn thng, bnh l ung th, tng tui th v
ng nhin nguy c xy ra s c hoc sai st y khoa lin quan hu ht n phu
thut.
Theo bo co ca B Y T Anh, trong sut 4 nm qua c ti 762 bnh nhn t
vong v nhng li sai lm ng ngn ca cc bc s trong qu trnh phu thut. Trong
s c ti 322 ngi bnh t vong v bc s b qun dng c y t trong ngi v 214
ca bnh thit mng v cc bc s ct nhm cc b phn ni tng ca bnh nhn. Ngoi
ra, 73 tai nn khc l do cc iu dng nhm ln a thc n vo dn lu mng phi
ca bnh nhn thay v a vo d dy v 58 trng hp cc bnh nhn qua i do b
45

cy ghp nhm ni tng hoc chn tay gi. Tin s Mile Durkin, Gim c Trung Tm
bo v s an ton ca bnh nhn thuc B Y T Anh cho bit bn cnh nhng li sai
ca cc bc s cc bnh vin gy nguy him ti tnh mng ca cc bnh nhn
c thng k, cn rt nhiu tai nn khc cha c cc bnh vin bo co chnh
xc. V Gim c ny cho bit Ban quan l dch v chm sc sc khe ca Anh cam
kt s khng cho php bt k s xut no gy nguy hi ti tnh mng bnh nhn xy ra
trong thi gian sp ti. Ngoi ra ng cn ni thm rng d ch l 1 li sai, mt tai nn
cng ng bo ng i bt k bnh vin no.
Nm 2011, B Y t i Loan c bo co chn ng v 5 trng hp bnh
nhn c ghp tng t mt ngi cho cht no c nhim HIV. Nguyn nhn c xc
nh sau l do sai st t trung tm iu phi ghp tng nhm ln d liu ca
bnh nhn cht no vi mt bnh nhn khc.
Vin Y hc M (Institute of Medicine) bo co gn y ti M cho thy t
1.500 n 2.500 cc trng hp phu thut sai v tr xy ra hng nm ti nc ny.
iu tra 1.050 phu thut vin bn tay thy 21% trong s h tng t nht 1 ln m
sai v tr trong s nghip ca mnh, cng nh vy s c xy ra 1/4 phu thut vin
chnh hnh c trn 25 kinh nghim lm vic c tnh hng nm ti M c gn
98.000 trng hp t vong v 1.000.000 trng hp b thng tn do s c y khoa.
Ngi ta cng c tnh nm 2000, ring chi ph gii quyt s c y khoa cng mt
khong 887 triu la.
C quan nh gi cht lng bnh vin (Joint Commission on Accreditation of
Healthcare Organization) sng lp t chc theo ri WSS Wrong Site Surgery Phu
thut sai v tr cho bit s c nhm v tr phu thut chim t xut l 1/27.686 bnh
nhn nhp vin, hoc 1/112.994 trng hp phu thut.
2. PHN LOI SAI ST, S C Y KHOA LIN QUAN TI PHU THUT
nh ngha s c, sai st y khoa lin quan ti phu thut, th thut.
a. Sai st (Error): L tht bi khi thc hin k hoch c ra trc hoc l
trin khai sai k hoch nn khng th t c mc ch. i khi l a ra
k hoch sai dn n sai st. Sai st cng c th xy ra khi lm ngc li vi k
hoch. V d, iu dng qun gc khi phu thut vin ng bng v lm
cho phu thut vin phi m li bng tm gc qun.
b. S c y khoa (Adverse event): Hoc cc tai bin/bin chng xy ra ngoi
mun, hu qu lm cho vic iu tr ko di, tng t l mc v t vong ca
ngi bnh.
Nu s c do nguyn nhn sai st, hon ton c th phng trnh c. V d,
trng hp st gc c ly ra v c th trnh c p xe trong bng. Tuy nhin
nhng trng hp sau phu thut bng c bin chng p xe nhng khng phi do
nguyn nhn st gc, th kh c th phng trnh. Theo cc chuyn gia, n hn 50%
cc trng hp s c l c th phng trnh c
-

Nhng sai st trong phn hnh chnh ca phu thut: Sai bnh nhn, sai v tr
phu thut, sai v c quan ni tng, qun dng c phu thut trong c th bnh
nhn.
Sai st trong phu thut: Phu thut vin c th ct sai hoc phm cc sai st
khc.
46

Sai st trong gy m: Nhiu thuc gy m qu hoc t qu (au hoc tnh dy

trong lc m).
Cc bin chng ca phu thut: Chy mu, thng tng, tn thng tng khc
Nhim khun sau phu thut: Cn gi l nhim khun do thy thuc.
Truyn sai nhm mu.

Phn loi s c, sai st theo mc nguy hi :

a. S c, sai st gn nh sp xy ra
- Do iu kin lm vic khng m bo
- S c xy ra nhng khng nh hng n ngi bnh do may mn
- S c xy ra nhng khng nh hng n ngi bnh do phn ng kp thi ca
nhn vin y t
b. S c xy ra nhng khng nguy hi n ngi bnh
- S c tc ng n ngi bnh nhng khng nguy hi, hoc sai st do s sao
nhng, v d qun a thuc , thuc a khng ng liu cho ngi bnh.
- S c tc ng n ngi bnh nhng c theo di gim st cht ch phng
nguy hi xy ra.
c. S c nguy hi n ngi bnh
- Ngi bnh b nh hng tm thi, cn phi iu tr can thip phu thut sa cha
- Ngi bnh b nh hng tm thi, cn phi ko di thi gian nm vin
- Ngi bnh b nh hng gy tc hi thng xuyn
- Ngi bnh b nh hng v cn phi can thip iu tr cu tnh mng
d. Cht
- Hu qu s c lm dn n t vong
3. NGUYN NHN CA CC SAI ST, S C Y KHOA LIN QUAN TI
PHU THUT, TH THUT
Cc bin chng xy ra lin quan n nhiu yu t nh: Li con ngi, li k
thut, thiu s phi hp ng b trong qu trnh thc hin phu thut nht l nhm gy
m v phu thut vin, cng nh li phng tin s dng do thiu hoc hng hc.
Cc thao tc phu thut thng rt phc tp v thng vp nhiu sai st . Cng
vic hnh chnh trong khoa ngoi cng c th dn n sai st. Trong mt s trng
hp, c nhng bin chng v nguy c ca phu thut d c d bo trc nhng
cng khng th trnh khi c.
Nhng nguyn nhn chnh dn n sai st, s c c xp theo mc :
- Bt cn/thiu quan tm
- Nhn vin cha c o to/thiu kinh nghim
- Tui v sc khoe ca Nhm phu thut
- Thiu thng tin lin lc
- Chn on sai
- Nhn vin lm vic qu sc, p lc cng vic
47

c toa thuc sai hoc sai st trong cp pht thuc, bao gm c vic ghi chp
khng r rng trong h s bnh n hoc do nhm nhn
Thiu cng c (Bng kim) chc chn mi th c kim tra k lng
Nhm Phu thut cha thc s n v gn kt
p lc gim thi gian phu thut
Phng php phu thut yu cu cc thit b hoc t th ngi bnh khc bit
Vn ha t chc/ lm vic
Mc thn thin, an ton ca mi trng lm vic
Chm sc / theo di tip tc sau phu thut
c im ngi bnh, nht l khi ngi bnh c nguy c nh: Bo ph, bt
thng gii phu,
S hiu nhm gia Ngi bnh Nhm phu thut do bt ng ngn ng:
khch du lch, dn tc thiu s
Do bn thn ngi bnh gy ra: Do ri lon thc, thiu s hp tc.

4. MI MC TIU AN TON PHU THUT THEO KHUYN CO CA

T CHC Y T TH GII
Da trn kt qu p dng th trn th gii, theo kin cc chuyn gia, WHO
ra 10 mc tiu chnh trong vic thc hin An Ton Phu Thut ATPT:
1) Phu thut ng bnh nhn, ng vng m
2) Khi lm gim au, x dng cc phng php ph hp trnh gy tn hi cho
bnh nhn.
3) nh gi v chun b i ph hiu qu vi nguy c tc ng th v chc
nng h hp
4) nh gi v chun b tt x l nguy c mt mu.
5) Trnh x dng hay thuc gy d ng nhng bnh nhn bit c nguy c
d ng
6) p dng ti a cc phng php gim thiu nguy c nhim trng ngoi
khoa
7) Trnh qun dng c m hay bng gc trong vng m
8) Kim tra i chiu k bnh phm phu thut
9) Thng bo kt qu v trao i thng tin n ngi t chc thc hin an ton
phu thut
10) Cc Bnh vin v h thng Y t thnh lp b phn c nhim v thng
xuyn theo di s lng v kt qu phu thut.
5.

NGHIN CU TNH HUNG V PHU THUT SAI V TR, SAI

NGI BNH, NGUYN NHN V BI HC
1/ Trng hp ngi bnh b b qun dng c sau m.

48

Hnh: Bnh nhn Donna v hnh kp phu thut b qun trong bng.
N bnh nhn 39 tui Donna c phu thut ct ti mt ti mt bnh vin
London, Anh. Thi gian di sau gia nh u khng h ngh ti vic bc s b
qun dng c y t trong bng b nn cng khng i kim tra ngay khi nhng cn au
bt u xut hin. Ngi bnh chu ng nhng cn au ny trong sut 3 thng v cho
rng nhng au n l do vt m. V cn au cng ngy cng nhiu hn nn Donna
quyt nh quay tr li bnh vin kim tra. Kt qu chp X quang cho thy mt
vt th l trong bng. Sau nhiu ln kim tra cc bc s xc nh l mt chic panh
phu tch di khong 18cm. Khi nhn c thng bo t cc bc s chn on hnh
nh, c gia nh Donna u v cng bc xc v sai lm nguy him ca cc bc s
tin hnh phu thut si mt cho b. Ngay sau khi pht hin s c, cc bc s tin
hnh phu thut a chic panh phu tch ra ngoi.
Hu qu khng mong mun :
Uy tn: Bc s phu thut b chuyn cng vic.
Kinh t: Bnh vin cam kt bi thng cho b Donna ton b chi ph iu tr,
cng nh do nh hng n cng vic.
Sc khe: V thi gian chic kp gp nm trong c th b Donna qu lu
cng vi s vn ng ca b trong sut thi gian sau khi phu thut khin cho hu
ht cc c quan ni tng trong bng b u b tn thng, v sc khe ca bnh nhn
b nh hng nhiu.
2/ Trng hp chu b b ct nhm Bng quang:
Bnh nhn Trn Anh , 21 thng tui. Ngy 23/10/2012 chu c gia nh
a n bnh vin thnh ph Cam Ranh, Khnh Ha khm v c bc s chn on
thot v bn v ch nh phu thut. Ca m c tin hnh ngy 25/10/2012 tuy nhin
sai st sy ra do bc s ct nhm vo bng quang. Bnh nhn phi tip tc chu thm
cc ln m tip theo khc ph s c ti bnh vin a khoa tnh Khnh Ha, sau
ti bnh vin Nhi ng 2 TP H Ch Minh m thng bng quang cng nm 2012.

49

Hnh: Bnh nhn Trn Anh . Ti BV Cam Ranh

n thng 6 nm 2013, chu c n ra bnh vin Nhi Trung ng, H Ni
tip tc phu thut theo ch o ca B Y t, v s h tr ca S Y t Khnh Ha.
Hu qu khng mong mun :
Uy tn: Bc s phu thut cho chu b b k lut cnh co. Bnh vin Cam Ranh
cng b nh hng t s c trn do bo ch nhc n nhiu thi gian qua.
Kinh t: Bnh vin Cam Ranh h tr u tin l s tit kim 230 triu ng, v
mt s chi ph khc trong thi gian chu i khm cha bnh, k c h tr tin tu xe ra
H Ni.
Sc khe: Sc khe chu khng c tt do nhiu ln m, 29 thng tui mi
ch c 10kg. Bn thn b m cng phi vt v i chm sc trong qu trnh chu nm
vin iu tr.
6.

HNG DN S DNG BNG KIM AN TON PHU THUT CA

T CHC Y T TH GII

Chng trnh phu thut an ton cu sng ngi bnh c t chc y t th

gii WHO xy dng nhm mc ch gim s ca bin chng v t vong lin quan
phu thut trn ton th gii. Nhng nguy c gy trong phu thut khng an ton nh
thiu thng tin v s kt ni ca cc thnh vin trong nhm phu thut, khng kim tra
k ngi bnh, vng m, cng nh phng tin s dng trong qu trnh phu thut...
Mc d l nhng iu kh ph bin nhng c th ngn nga c. Vi s gip ca
cc chuyn gia, phu thut vin, gy m hi sc, iu dng v chuyn gia v an ton
ngi bnh xc nh nhng mc tiu c bn ca an ton phu thut v a vo
Bng kim v a vo p dng. T bng kim u tin do WHO xut, nm 2009
chnh sa l Bng kim cui cng gm c 16 mc cho ph hp vic p dng v c
a s cc chuyn gia tn thnh. Chng ti xin c gii thiu y.
s dng bng kim, bnh vin, khu m cn phn cng vic c th cho nhn
vin ph trch vic in thng tin bng kim. Thng l iu dng ca khu m:
Nhn vin chy ngoi, hoc c th l bt k nhn vin no tham gia cuc m.

50

Trong Bng kim ny cm t Nhm phu thut c hiu l bao gm cc bc

s phu thut, bc s gy m, iu dng v k thut vin, v cc nhn vin khc ca
nhm lin quan n phu thut. Tuy phu thut vin ng vai tr quan trng i vi
thnh cng cuc m, xong vic chm sc ngi bnh cn phi c s phi hp ca ton
nhm. Mi thnh vin ca Nhm phu thut u c vai tr ring trong vic m bo
s an ton v thnh cng ca ca phu thut.
Bng kim c chia ra lm 3 giai on, mi giai on li tng ng vi mt
thi im c th trong quy trnh thao tc: Giai on tin m Giai on gy m v
trc khi rch da Giai on trong sut qu trnh phu thut, ngay sau khi ng da v
chun b chuyn ngi bnh ra khi phng m.
Ngi ph trch Bng kim cn phi xc nhn rng nhm mnh hon thnh
nhng phn vic trc khi chuyn sang giai on khc.
Giai oan tin m:
Tt c nhng bc cn c kim tra bng li vi mi thnh vin c lin quan
trong Nhm phu thut m bo rng nhng hnh ng ch cht c thc hin.
Do vy trc khi gy m ngi ph trch Bng kim s kim tra li bng li vi bc s
gy m v ngi bnh (trng hp ngi bnh c th ni c) xc nh nhn
dng, phng php v vng m l ng khi ngi bnh ng cho tin hnh phu
thut. Trng hp ngi bnh khng th xc nhn c v nhiu l do nh: Bnh nhn
m, tr em mt ngi gim h ca gia nh ngi bnh s ng ra chu trch
nhim. Tnh hung cp cu m khng c ai gim h c, c nhm s hi thng
nht thc hin bc ny.
Ngi ph trch Nhm phu thut din t bng li v hnh nh xc nhn
rng vng m c nh du (nu ph hp). Vic nh du vt m do phu thut
51

vin thc hin (thng bng bt) nht l trong trng hp c lin quan n nhng v
tr c c hai bn (bn tri v bn phi) hoc phi hp nhiu lp, tng (ngn tay, chn,
t sng ). Vic nh du nht qun trong tt c cc trng hp, nhiu khi l c s
xc nhn ng th thut v ng ch cn phu thut.
Sau h s trao i vi bc s gy m cc vn quan tm: Nguy c mt mu,
kh th, d ng ca ngi bnh, cng nh hon tt vic kim tra ton b my mc gy
m v thuc gy m. L tng nht l phu thut vin nn c mt thi im ny v
nhng thng tin trao i s gip cho bc s phu thut bit c din bin ca m v
nhng nguy c c th xy ra nh tin lng mu mt, d ng, cc yu t bin chng
khc ca ngi bnh.
Kim tra thit b o bo ha oxy trong mu gn trn ngi bnh m bo
thit b hot ng bnh thng l mt khu quan trng, nn ch d quan st thy ca
c nhm. Vic s dng thit b o bo ha oxy mu c WHO c bit khuyn co
bo m an ton gy m. Trng hp bnh nhn cn phu thut khn cp cu tnh
mng, nhng thit b ny c vn th c nhm cn phi thng nht b qua v c s
theo di cht ch trong sut qu trnh phu thut.
Ngoi cc vn c lu nh ngi bnh c tin s d ng ? ngi bnh c
biu hin kh th/nguy c ht kh th iu chnh phng php gy m ph hp,
v d, gy m vng nu c th v chun b sn cc thit b cp cu cn thit. Vic gy
m ch c th tin hnh khi bc s gy m xc nhn c y cc thit b v s h
tr cn thit bn cnh ngi bnh i vi nhng ngi bnh c nguy c nh hng
ng th hoc c biu hin kh th.
Vic mt mu trong qu trnh phu thut c d tnh trc, c bit lu kh
nng mt trn 500ml mu (hoc tng ng 7ml/kg tr em). Trc m cn c
tnh ton d tr mu. Trong qu trnh phu thut, phu thut vin thng xuyn trao
i vi bc s gy m v nhm iu dng chun b ng truyn khi cn.
Giai on gy m v trc khi rch da :
Trc khi rach da, mi thnh vin trong nhm s gii thiu tn tui v vai tr.
Nu l nhm tham gia phu thut hng ngy th ch cn xc nhn mi ngi trong
nhm c mt y v xc nhn mi ngi trong nhm u bit nhau. Ln na
ton nhm cn xc nhn h thc hin phu thut cho ng ngi bnh v xc nhn
bng li gia cc thnh vin, sau l nhng im ch yu trong cc k hoch phu
thut s dng Bng kim lm c s hng dn.
Mi ngi cng xc nhn vic s dng khng sinh d phng trong vng 60
pht trc m. Nu khng sinh d phng cha c dng, cn cho ngay trc khi rch
da. Trng hp cho ngi bnh s dng khng sinh qu 60 pht Nhm phu
thutc th cn nhc b xung nu cn. Trng hp khng sinh d phng c cho
l khng ph hp (khng rch da, ngi bnh b nhim khun trc v dng
khng sinh ri) th s nh du vo khng p dng vi s xc nhn ca c nhm.
Tip theo , c nhm cn lin tc trao i cc thng tin nh: Tin lng cc
bin c, nhng bc chnh v d tnh c xy ra vic g bt thng trong m? Thi gian
phu thut d kin? Nhng lo ngi v pha phu thut vin, v pha bc s gy m
iu dng kim tra li tnh trng v trng ca vng m ngi bnh, cng nh cc
dng c, thit b trc khi tin hnh rch da : my ht, dao m in, dn m ni soi
52

Hnh nh hin th ti phng m l vic cn thit m bo cho vic ln k hoch m

nh ng m, cch thc phu thut...Hin th hnh nh cn c m bo c trong
sut qu trnh phu thut.
Giai on trong sut qu trnh phu thut, ngay sau khi ng da v chun b
chuyn ngi bnh ra khi phng m:
Trc khi ri phng m, c nhm nh gi li cuc m, hon thnh vic kim
tra thit b s dng cho cuc m, gc phu thut v dn mc bnh phm phu thut. Do
trong qu trnh phu thut c th thay i hoc m rng ty theo tnh trng tn thng
nn ngi ph trch Bng kim cn xc nhn vi Nhm phu thut xem chnh xc l
phu thut/th thut g c thc hin. Cu hi thng t ra nh Chng ta va
tin hnh th thut/phu thut g ?? hoc xc nhn Chng ta va tin hnh th thut
X c ng khng ??
Mt bc khng km phn quan trng l dn nhn bnh phm hoc c to nhn
bnh phm bao gm c tn ngi bnh. Do vic dn nhn khng ng bnh phm l
nguy c tim n i vi ngi bnh, thm ch mt bnh phm s dn n nhng sai st
hoc kh khn trong vic iu tr ngi bnh v sau nn vic dn nhn cn c lu .
Ngi ph trch cn xc nhn vic dn nhn bnh phm thu c trong qu trnh phu
thut l ng bng cch c to tn ngi bnh, m t bnh phm v ghi thng tin
ngi bnh ln trn.
Nhm phu thut cng cn nh gi li hot ng ca trang thit b, nhng
hng hc xy ra nu c hoc nhng vn lin quan cn gii quyt.
Cui cng c nhm s trao i k hoch chnh v nhng vn lin quan ti x
l hu phu v phc hi ca ngi bnh trc khi chuyn ngi bnh ra khi phng
m.
Trong qu trnh phu thut, c bit cc phu thut phc tp, nhiu chuyn
khoa vic c ngi ph trch Bng kim gim st mi thnh vin, trnh b st
trong tt c mi Giai on. Chng no m cc thnh vin ca Nhm phu thut cn
phi lm quen vi nhng khu lin quan, ngi ph trch Bng kim s tip tc hng
dn c Nhm phu thut thng qua quy trnh bng kim ny.
Do ngi ph trch Bng kim c quyn dng khng cho tin hnh cc bc
tip theo nu cc bc trc cha c hon thnh, m bo cho cuc m an ton
nn h c th gp xung t vi mt vi cc thnh vin khc ca nhm. V vy vic la
chn ngi ph trch Bng kim cn ph hp: C trch nhim v c c ting ni i
vi mi ngi.
7.

GII PHP BO M AN TON NGI BNH TRONG PHU

THUT, TH THUT

1. Gii php chung phng nga s c y khoa trong phu thut

vic thc hin phu thut thnh cng, gim thiu nguy c bin chng v s
c, mi nhn vin y t lin quan n chm sc ngi bnh cn phi nm r thng tin
ca ngi bnh, hiu r v chc nng sinh l ca ngi bnh cng nh loi bnh h
mc phi, phng thc phu thut, vn tm l, thng tin thnh cng ca ca phu
thut v s phc hi ca ngi bnh.
53

Bn cnh , cn chun b k lng trc mi ca phu thut t nh n ln, t

n gin n phc tp: Thuc, mu, dch truyn, cc phng tin cn thit m
bo ung ng tt nht cho cuc m thnh cng, cng nh cc bin chng xy ra sau
ny.
Mt trong nhng yu t quan trng thc hin phu thut an ton l s gn
kt nhm phu thut (phu thut vin, bc s gy m, iu dng v nhm ph gip)
v thng tin y v ngi bnh cng nh phng php phu thut s c tin
hnh.
Yu t con ngi ng vai tr quan trng trong vic phng nga s c, sai st y
khoa trong phu thut, gm nhiu yu t nh trnh chuyn mn, tui tc v sc
khe, phn cng cng vic hp l, c bit l c cnh bo v s c v nhng bin
php phng nga. Bnh vin c th a ra chnh sch nh khen thng, ng vin kp
thi nhng trng hp trnh c s c v sai st, pht hin v s tr s c kp thi,
cu c ngi bnh
Cc bnh vin, c s y t nn t chc cc kha hc hoc ta m ch sai st,
s c y khoa nhc nh nhn vin y t thng xuyn. Mt v d l Trung tm phu
thut v ung th thuc trng i hc Hong gia London tin hnh chng trnh
tp hun v an ton phu thut cho gn 50 nhn vin y t. Kin thc v an ton phu
thut tng t 55% (test trc kha hc) ln 68% (test sau kha hc). Tt c u hiu
v t tin v vic nh gi an ton ngi bnh ti phng m.
Ci thin iu kin lm vic cng l mt yu t quan trng phng nga s c
nh cung cp y phng tin lm vic, gim ti cng vic, nhn vin y t c
ch ph cp v ngh ngi c th ly li sc khe p ng cng vic.
C h thng bo co s c thng xuyn, kp thi mi ngi c bit v
cnh bo v vic ny trong cng vic hng ngy.
2. p dng Bng kim an ton phu thut
T chc Y t Th gii c gng n lc lm gim bt cc nguy c dn n
vic phu thut khng an ton nh xy dng chng trnh an ton ngi bnh, bao
gm an ton phu thut, p dng bng kim - check list trong phng phu thut
Mc ch ca chng trnh ny to nn s phi hp, chia x thng tin cng nh vic
chun b tt ngi bnh gia cc nhm chm sc v phu thut, gy m lin quan qu
trnh tin hnh phu thut t phng bnh n phng bnh (room to room) c ngha l
ngi bnh c an ton t lc ri khi phng bnh cho n khi tr li phng bnh.
Bng kim c p dng ti nhiu nc trn th gii v cho thy hiu qu r rt.
c s gip ca WHO, Vit nam tin hnh p dng th bng kim bc u
ti mt s c s ngoi khoa ln nm 2011 v cho kt qu rt kh quan.
Bng kim ATPT c p dung trn th gii v cho kt qu kh quan qua
nhiu s liu v cc bo co lin quan.
Theo bo co ca WHO nghin cu th nghim 8 Bnh vin trn ton cu:
7.688 BN (3.733 trc v 3.955 sau thc hin Checklist) t 10-2007 n 9- 20080.
Bin chng ln gim t 11% n 7% (gim36%), t l t vong ni tr gim t 1,5%
n 0,8% (gim gn 50%).
Mt nghin cu khc v vic p dng Checklist An ton phu thut ti 6 Bnh
vin H lan (Netherland) qua 3.760 trng hp trc v 3.820 sau p dng
54

Checklist An ton phu thut: Bin chng gim t 27,3% n 16,7%, t vong ti Bnh
vin gim t 1,5% n 0,8%. Trong khi khng thay i kt qu 5 Bnh vin kim
chng.
Theo mt nghin cu ca Armndo C.Crriostomo, ti Philippines 40 Bnh vin
/102 phng m giai on 2/ 2009 12/2009 qua 44.359 phu thut: T l x dng
Checklist = t 24 n 100%, t l bin chng = 0,38 2,3%. T l bin chng v t
vong cao hn nhng bnh vin c t l x dng Checklist thp.
Khoa phu thut, bnh vin Johns Hopkins, Baltimore M nm 2011 trin khai
an ton phu thut ton din, theo di thi gian 12 thng thy t l nhim khun vt
m gim t 27,3% xung cn 18,2% sau khi tin hnh cc bin php can thip.
Theo Eefje N de Vries, vic s dng bng kim an ton phu thut gip gim
t l bin chng t 11% xung cn 7%. Tuy nhin nhiu cc bo co cho thy hu ht
cc bin c (t 53 n 70%) li xy ra ngoi phng m, vy vic p dng bng kim
v thc hin an ton phu thut cn phi tin hnh nghim tc ngoi phng m ch
khng ch phng m v trong cuc m. Nghin cu c tin hnh ti 5 bnh vin,
cho thy t l t vong gim c 0.1% ( t 1.2 % xung 1.1% ) sau khi thc hin p
dng bng kim.
Bnh vin HN Vit c, mt trung tm ln v ngoi khoa ca c nc, cng
vi mt s cc bnh vin tin hnh p dng th Bng kim ATPT trong nm 2010
theo khuyn co ca WHO cho kt qu tt. nh gi chung l Bng kim ph hp,
n gin v d thc hin, to iu kin kim sot phu thut an ton v hiu qu. Tuy
nhin c th chnh sa mt s thng tin c th p dng tt c cc bnh vin.
Trin khai an ton trong phu thut l mt chng trnh m B Y t ra
(Thng t s 19/2013/TT-BYT v trin khai cc bin php bo m an ton ngi
bnh v nhn vin y t). Do vy mi nhn vin y t ti cc c s y t chm sc ngi
bnh cn bit v thc hin nghim tc.
Trn c s php l ny cng nh hiu qu ca p dng Bng kim trn th gii,
vic trin khai p dng Bng kim ATPT c coi nh mt trong nhng bin php hu
hiu nhm gim thiu s c, sai st y khoa lin quan n phu thut trong iu kin
ca Vit Nam hin nay.
8.

KT LUN

Sai st y khoa, c bit l cc sai st v s c lin quan n phu thut gy thit

hi cho ngi bnh, gy lng ph, tn km khng cn thit, lm gim cht lng iu
tr, lm mt uy tn ca bnh vin.
Tnh trng cng vic cng thng lin tc cc c s y t khin nhn vin rt
mau mt mi v d phm phi nhng sai st y khoa.
Cn nhn r nhng nguy c v nhng ri ro tim tng c bin php phng
trnh tch cc.
Cn c b phn qun l ri ro trong mi c s y t gii hn n mc thp
nht cc sai st trong thc hnh y khoa.
Cc nhn vin y t cn c gio dc thng xuyn v tc hi ca cc sai st y
khoa v cch thc, qui trnh cn tun th nghim ngt phng trnh sai st.
55

Bng kim ATPT c coi l cng c hiu qu p dng ngn nga s c, sai
st y khoa lin quan n phu thut trong iu kin Vit Nam hin nay.

TI LIU THAM KHO

1. Hull L, Arora S, Amaya AC, Wheelock A, Gaitan Duarte H, Vincent C et al.
Building global capacity for patient safety: a training program for surgical safety
research in developing and transitional countries. Int J Surg.2012;10 (9) : 493-9.
2. Wick EC, Hobson DB, Bennett JL, Demski, Maragakis L, Gearhart SL, Efron J,
Berenholtz SM, Makary MA. Implementation of a surgical comprehensive unitbased safety program to reduce surgical site infections. J Am Coll Surg.2012
Aug:215(2):193-200.
3. Mendelsohn D; Bernstein M. Patient Safety in Surgery. Israel Journal of Emergency
Medicine.Vol.9,No.2 July 2009.
4. Thng t s 19/2013/TT-BYT ngy 12 thng 7 nm 2013 ca B Y t v Hng dn
thc hin qun l cht lng dch v khm bnh, cha bnh ti bnh vin
5. World Alliance for Patient Safety. WHO Guidelines for Safe Surgery ( First
Edition). World Health Organization.
6. Eefje N. De Vries; Hubert A. Prins ; Rogier M.P.H Crolla; Adriaan J.Den Outer;
George van Andel et al. Effect of a Comprehensive Surgical Safety on Patient
Outcomes. N Engl J Med 2010;363:1928-1937.
7. Implementation Guidelines Safe Surgery Through Better Communication Quality
in Medical Care Section. Medical Development Division. Ministry of Health
Malaysia. Nov. 2009.
8. Deborah F. Molloy; Ronda G. Hughes. Chapter 36 Wrong-Site Surgery : A
Preventable Medical Error. WHO guidelines on Patient Safety.
9. Catherine J.Chamberlaim, Leonidas G.Koniaris, Albert W.Wu, Timothy
M.Pawlike. Disclorure of Nonharmful medical errors and other events. Arch
Surg.2012; 147(3):282-286
10. Gawanda AA. An Apgar score for surgery. Journal of the American College of
Surgeon, 2007;204: 201-8
11. Surgical Safety Checklist. Revised 1/2009 WHO,2009
12. B Y t. Ti liu o to an ton ngi bnh
13. WHO. Patient Safety Curriculum Guideline, Multi-professional Edition, 2011.

56

CU HI LNG GI
A. La chn p n ng nht:
Cu 1. nh ngha v sai st trong y khoa:
A. L tht bi khi thc hin k hoch khng c ra trc hoc l trin khai
sai k hoch nn khng th t c mc ch.
B. L tht bi khi thc hin k hoch c ra trc hoc l trin khai sai k
hoch nn khng th t c mc ch.
C. L tht bi khi thc hin k hoch c ra trc mc d l trin khai
ng k hoch nn khng th t c mc ch.
Cu 2. Trong cc v d di y, v d no c coi l s c y khoa:
A. Ngi bnh t vong do bnh qu nng d c iu tr v chm sc tn tnh.
B. Phu thut vin khng kim tra li ngi bnh trc khi phu thut dn n
phu thut sai v tr.
C. Ngi bnh vim phi do cao tui v do th my lu ngy.
Cu 3. Phn loi s c, sai st theo mc nguy hi c bao nhiu mc?
A. 1
B. 2
C. 3
D. 4
B. in vo ch trng:
Cu 4. Nhng sai st trong phn A.: sai bnh nhn, sai v tr
B, sai v c quan ni tng, qun dng c phu thut trong c th bnh nhn.
A.
B.
Cu 5. Sai st trong A: Nhiu qu hoc t quB(au hoc tnh
dy trong lc m).
A.
B.
Cu 6. Nhng nguyn nhn chnh dn n sai st
Bt cn/.
Thiu
Chn on
C. Cu hi ng sai:
Mc tiu chnh trong vic thc hin An Ton Phu Thut:
STT
Ni dung
1.
Phu thut ng bnh nhn, ng vng m
2.
Khi lm gim au, s dng cc phng php ph hp v thun
tin cho ngi thc hin.

57

3.
4.
5.
6.
7.
8.
9.
10.

nh gi v chun b i ph hiu qu vi nguy c tc ng

th v chc nng h hp
nh gi v chun b tt x l nguy c mt mu
Khng cn tm hiu cc loi thuc gy d ng nhng bnh
nhn bit c nguy c d ng
p dng tng i cc phng php gim thiu nguy c
nhim trng ngoi khoa
Trnh qun dng c m hay bng gc trong vng m
Kim tra i chiu k bnh phm phu thut
Ch cn thng bo kt qu n ngi t chc thc hin an ton
phu thut
Cc Bnh vin v h thng Y t thnh lp b phn c nhim v
thng xuyn theo di s lng v kt qu phu thut.

58

Bi 5
TNG QUAN V KIM SOT NHIM KHUN
TRONG CC C S Y T V GII PHP
MC TIU
Sau khi hc xong bi ny, hc vin c kh nng:
1.
2.
3.
4.

Trnh by c nh ngha nhim khun lin quan ti chm sc y t

Phn tch c thc trng nhim khun lin quan ti chm sc y t
Trnh by c nguyn nhn nhim khun lin quan ti chm sc y t
Trnh by c cc gii php Phng v kim sot nhim khun

1. S CN THIT
Bn cht cc bnh truyn nhim l c kh nng ly nhim rt cao, duy tr s tri
dy v ti xut hin qua tng thi k. Hin nay, s xut hin ca cc tc nhn gy
bnh nguy him nh HIV, HBV, HCV; cc dch bnh do vi rt SARS, Cm AH5N1,
H1N1, H7N9 v cc vi sinh vt a khng lm cho trng tm ca cng tc kim sot
nhim khun c nhiu thay i. Trc y, ch yu tp trung vo ngi bnh v c
bit l ngi bnh c phu thut, nay cng tc phng nga nhim khun phi tp
trung cho c ngi bnh v cn b y t, khng ch c phu thut m tt c ngi bnh
c cc can thip th thut xm ln1.
Cc thut ng dng m t tnh trng nhim khun cng c thay i t
Nhim khun bnh vin - Nosocomial infection hoc Hospital Infection sang
Nhim khun mc phi trong bnh vin - Hospital Acquired Infection v nay thut
ng hay c cc nh nghin cu y hc s dng l Nhim khun lin quan ti chm
sc y t - Health Care Asociated Infection-HCAI.
Nhim khun lin quan ti chm sc y t ang lm hng triu ngi bnh trn
Th gii b nh hng hng nm v l nguyn nhn hng u lm nh hng ti s an
ton ca ngi bnh v cht lng dch v y t. V vy, cng tc Phng v kim sot
nhim khun lun l thch thc i vi h thng y t ton Th gii v l mt trong
nhng u tin hng u trong Chng trnh bo m an ton ngi bnh.
2. DCH T HC NHIM KHUN BNH VIN
2.1. nh ngha
Theo T chc Y t Th gii (TCYTTG), NKBV c nh ngha l Nhim
khun ngi bnh mc phi trong thi gian iu tr ti bnh vin v nhim khun
khng phi l l do nhp vin v/hoc nhim khun xy ra vi ngi bnh trong bnh
vin hoc c s y t khc m nhim khun ny khng hin din hoc khng trong giai
on bnh ti thi im nhp vin 6. Nhim khun bnh vin thng xut hin sau
48 gi k t khi ngi bnh nhp vin (xem s 1).

S 1:Thi gian xut hin NKBV

59

 chn on NKBV ngi ta da vo nh ngha v tiu chun chn on cho

tng v tr NKBV nh: Nhim khun vt m, Vim phi bnh vin, Nhim khun
huyt lin quan n dng c t trong lng mch, Nhim khun ng tit niu v,v,.
Cc nh ngha v tiu chun chn on ny c s dng gim st NKBV trn
ton cu.
Nhim khun lin quan n c s khm bnh, cha bnh (KBCB) khng ch l
ch s cht lng chuyn mn, m cn l ch s an ton ca ngi bnh, ch s nh
gi s tun th v thc hnh ca nhn vin y t (NVYT), ch s nh gi hiu lc ca
cng tc qun l v l mt ch s rt nhy cm i vi ngi bnh v x hi.
2.2. Tn sut nhim khun bnh vin
Cc nghin cu quy m vng, quc gia v lin quc gia ca cc nc v T
chc Y t Th gii ghi nhn t l NKBV t 3,5% n 10% ngi bnh nhp vin. Ti
cc nc ang pht trin, t l NKBV t 5-15% v t l NKBV ti cc khoa hi sc
cp cu t 9-37% 6,7. Ti Anh quc c >100.000 ngi bnh NKBV/nm lm tng 25
triu ngy iu tr ti bnh vin6,7.. Ti M: T l NKBV chung 4,5% ngi bnh
nhp vin (2002), c gn 100.000 ngi bnh t vong lin quan ti NKBV 6,7.. Ngy
iu tr trung bnh cho mt ngi bnh nhim khun lin quan ti chm sc y t ln
ti 17,5 ngy v chi ph hng nm gii quyt hu qu NKBV ln ti 6,5 t USD
(2004) 6,7.
Tnh hnh NKBV ti Vit Nam cha c xc nh y do c t ti liu v
gim st v NKBV c cng b. n nay c ba cuc iu tra ct ngang (point
prevalence) mang tnh khu vc do V iu tr B Y t (nay l Cc Qun l khm,
cha bnh) c thc hin. Ngoi ra, cc s liu iu tra t l NKBV hin mc ca
cc bnh vin a khoa tuyn tnh u ghi nhn t l NKBV chung t 4,2-8,1% 1, 2, 3, 4, 5.
Xem bng 1 di y:
Bng 1. T l NKBV hin mc ti mt s bnh vin Vit Nam.
Nm
2000
2001
2005
2005
2005
2011
2012
2012
2013

T l
NKBV
S Y t TpHCM gim st NKBV ti 4 BV
8,1
B Y t. Nhim khun bnh vin ti 11 bnh vin trc thuc B 6,8
Y t.
B Y t. Nhim khun bnh vin ti 19 bnh vin trc thuc 5,8
B Y t. (n=11.000 NB)
Nguyn Thanh H. Nhim khun bnh vin ti 6 BV Pha Nam 5,6
(n=2.671)
Nguyn vit Hng. Tnh hnh NKBV ti 36 bnh vin Pha Bc 7,8
(2TW, 17 tnh, 17 huyn); n=7.541 NB
BVK Ha Bnh. NKBV Trn bnh nhn s sinh (n=322)
6,5
BVK Bnh nh. iu tra NKBV (n=763)
5,9
BVK H Tnh. iu tra NKBV (n=353)
4,2
Bnh vin Xanh Pn H ni. Thc trng NKBV ti cc khoa 8,4
lm sng 2013 (n=414)
Cc nghin cu

2.3. Cc Nhim khun bnh vin thng gp

60

Vim phi bnh vin (VPBV): Theo cc nghin cu cc nc pht trin,

VPBV chim 15% trong tng s cc loi NKBV, chim ti 27% trong cc NKBV
khoa HSTC (CDC 2003). Trong s cc VPBV, loi VPBV lin quan n th my
(xut hin sau khi th my 48 gi) chim t l 90%. VPBV lm ko di thi gian
nm vi n khong 6,1 ngy lm tn thm chi ph khong 10.000 USD n 40.000 USD cho
m t trng hp. T l NKBV do vim phi chim t l cao nht trong s cc NKBV
khc: 55.4% trong tng s cc NKBV (B Y t, 2005). Theo cc nghin cu cc
5
b nh vi n trong ton quc, t l VPBV trn cc bnh nhn th my t 17,4%-39,4%
.
T l nhim khun vt m (NKVM): Ti cc bnh vin Vit Nam, mt s iu
tra NKVM gn y ghi nhn t l NKVM t 3,2-12,6%. Chi tit xem bng 2 di
y:
Bng 2. T l nhim khun vt m
Nm

Nghin cu

T l
nhim
khun

2002 BV Thanh Nhn. Gim st NKVM (n=626)

4,0

2004 BV Vit c. NKVM chung (n=807 NB)

3,2

2008 BVTW Hu gim st NKVM (n= 1.000 NB)

4,3

2010 BV Xanh Pn. Tnh hnh NKVM ti khoa phu thut to hnh
(n=241)

5,8

2010 Bnh vin tim h Ni. Thc trng nhim khun vt m trn bnh
nhn phu thut tim (n=1.289)

12,6

2011 BVK Nng. Tnh hnh NKVM (n=2250)*

5,2

2012 BVK Bnh nh. nh gi NKVM (n=622)

8,4
Nhim khun vt m li hu qu nng n cho ngi bnh do ko di thi gian
nm vin, tng t l t vong v tng chi ph iu tr. Ti Hoa K, s ngy nm vin
gia tng trung bnh do NKVM l 7,4 ngy, chi ph pht sinh do NKVM hng nm
khong 130 triu USD. Mt vi nghin cu Vit Nam cho thy NKVM lm tng
gp 2 ln thi gian nm vin v chi ph iu tr trc tip.
Nhim khun ng tit niu: Nhim khun bnh vin ng tit niu ng
hng th hai hoc ba ty theo nghin cu, t l mc cao nhng ngi gi, ngi c
t thng tiu. C ti 80% trng hp nhim khun ng tit niu lin quan n t
dn lu bng quang v t l nhim khun tit niu nng rt cao trong mt s trng
hp nh thay thn, n gii, i ng v suy thn. Nhim khun tit niu bnh vin
thng do trc khun Gram m, trong hay gp nht l Escherichia coli, Proteus
mirabilis, Klebsiella spp v P.aeruginosa; ngoi ra cn c th gp Enterococci v
Enterobacter spp. Nm Candidas cng c xem l mt trong nhng nguyn nhn
hng u gy nhim khun tit tiu khoa HSTC.
Nhim khun huyt (NKH): Nhim khun huyt ng hng th 3 trong cc
NKBV thng gp trong cc c s khm bnh, cha bnh (KBCB). Nghin cu ti
cc khoa HSTC ca M cho thy tn sut ca NKH l 5,5 ca/1000 ngy iu tr ti
khoa HSTC ngi ln v 7,7/1.000 ngy mang catheter. Theo gim st quc gia M
61

c xp x khong 80.000 NKH c lin quan ti t catheter trn tng s 250.000 ca

NKH xy ra hng nm v l nguyn nhn gy ra 2.400 - 20.000 ca t vong/nm. Chi
ph trung bnh cho 1 ca c NKH l t 34.508 USD - 56.000 USD v tng chi ph c th
ln ti 296 triu - 2,3 t USD/ nm. Ti Vit Nam, nghin cu NKH khoa HSTC s
sinh trn bnh nhn c t catheter cho thy tn sut l 7,5 ca/1.000 ngy iu tr. Chi
ph nhng tr c NKH cao hn nhiu so vi tr khng c NKH, ngy iu tr ko
di thm 8 ngy. Tn sut ti khoa HSTC nhi chung l 9,6/1.000 tr nhp khoa HSTC.
Nhim khun vt bng: Ngi bnh bng, b mt da b tn thng, s kt hp
gia tnh trng bnh v s dng dng c xm ln trong qu trnh iu tr l iu kin
thun li cho NKBV, t cu vng v Pseudomonas l vi khun khng thuc thng
phn lp c trong tn thng nhim trng bng. Mt khc, vt bng su, m hoi
t l mi trng thun li cho VSV xm nhp, pht trin v d gy nhim khun
huyt. Cc chng vi khun phn lp c t bnh phm m nhim trng bng qua
nhiu cng trnh nghin cu cho thy thng gp l Pseudomonas spp,
Staphylococcusaureus v Klebsiella spp.
Cc nhim khun khc: Ngoi mt s loi NKBV thng gp ni trn cn
nhiu loi nhim khun khc trong bnh vin nh: Nhim khun da v m mm,
nhim khun d dy - rut, vim xoang, nhim khun mt v kt mc, vim ni mc
t cung
2.4. Cc tc nhn vi sinh vt
Vai tr gy bnh ca vi khun:
Vi khun gy NKBV c th t hai ngun gc khc nhau. Vi khun ni sinh,
thng c tr lng, tuyn m hi, tuyn cht nhn. Bnh thng trn da c khong
13 loi vi khun i kh c phn b khp c th v c vai tr ngn cn s xm nhp
ca VSV gy bnh. Mt s vi khun ni sinh c th tr thnh cn nguyn nhim
khun khi kh nng bo v t nhin ca vt ch b tn thng. Vi khun ngoi sinh, l
vi khun c ngun gc ngoi lai, c th t dng c y t, nhn vin y t, khng kh,
nc hoc ly nhim cho gia cc bnh nhn.
Vi khun Gram dng: Ch yu l cu khun. T cu vng (Staphylococcus
aureus) ng vai tr quan trng i vi NKBV t c hai ngun ni sinh v ngoi sinh.
T cu vng c th gy nn nhim khun phi, xng, tim, nhim khun huyt v
ng vai tr quan trng trong NKBV c lin quan n truyn dch, ng th, nhim
khun vt bng v nhim khun vt m. Vi khun Staphylococcus saprophyticus
thng l cn nguyn gy nhim khun tit niu tin pht, l loi gy nhim khun c
t l cao th hai (sau t cu vng) ngi bnh nhim khun vt bng. Lin cu beta
tn huyt (beta- hemolytic) ng vai tr quan trng trong cc bin chng vim mng
c tim v khp.
Vi khun Gram m, trong cc trc khun Gram (-) thng c lin quan nhiu
n NKBV v ph bin trn ngi bnh nhim khun phi ti khoa iu tr tch cc.
H vi khun ng rut (Enterobacteriaceae) thng c tr trn ng tiu ho ca
ngi v ng vt, ang l mi quan tm ln trong NKBV do c kh nng khng cao
vi cc nhm khng sinh amiglycoside, -lactamase v c kh nng truyn tnh khng
qua plasmid. Acinetobacter spp, trong ng quan tm nht l loi A.baumannii,
thng gp trong khng kh bnh vin, nc my, ng thng niu o, my tr h
hp. Ngoi ra cn thy vi khun ny trong m, nc tiu, phn, dch nhy m o.
62

Ngy nay NKBV do Acinetobacter spp ang c chiu hng gia tng r rt. Vi khun
thuc ging Klebsiella spp thng xuyn l nguyn nhn NKBV v vi khun ny c
kh nng lan nhanh to thnh cc v dch ti bnh vin. Loi Klebsiella pneumoniae,
thng c vai tr quan trng trong nhim khun tit niu, phi, nhim khun huyt v
m mm. Nhiu nghin cu trong nc v quc t khng nh, vi khun
Escherichia coli gy nhim khun ch yu trn ng tit niu, sinh dc ca ph n
v nhim khun vt m.
Trc khun m xanh (Pseudomonas aeruginosa), l vi khun Gram (-), a kh
thuc h Pseudomonadaceae. Ngi bnh nhim khun c pht hin thy trc
khun m xanh phi, mt trong bng quang, b thn, bung t cung, thnh ng dn
lu v b mt kim loi my to nhp tim. Cc vi khun gy nhim khun huyt trn
ngi bnh bng ch yu l trc khun m xanh v t cu vng, trong trc khun
m xanh khng hu ht cc khng sinh thng thng.
Nhiu nghin cu trong nc v nc ngoi u chng minh trc khun Gram
m l cn nguyn hng u gy nhim khun c hi v cc loi thng gp l
P.aeruginosa, Acinetobacter spp, E.coli, Klebsiella spp v Enterobacter spp. iu tra
NKBV v cc yu t lin quan ti 19 bnh vin, Phm c Mc v cng s (2005)
cho thy cc tc nhn nhim khun chnh l P.aeruginosa (24%), sau l
K.pneumoniae (20%) v A.baumannii (16%). Trng Anh Th (2008), nghin cu ti
Bnh vin Bch Mai bo co nhim khun do P.aeruginosa cao nht (28,6%), sau
l A.baumannii (23,8%), K.pneumoniae (19%) v nm candida spp (14,3%). Nguyn
Vn Ha (2008), ti Bnh vin Hu ngh Vit X, t l phn lp c P.aeruginosa l
cao nht (22,3%) v ng vai tr chnh trong nhim khun ng h hp v ng
tit niu.
Vai tr gy bnh ca vi rt: Mt s vi rt c th ly NKBV nh vi rt vim gan
B (HBV), vi rt vim gan C (HCV) (ly qua ng mu nh lc mu, tim truyn, ni
soi), cc vi rt hp bo ng h hp, SARS v vi rt ng rut (Enteroviruses)
truyn qua tip xc t tay-ming v theo ng phn-ming. Cc vi rt khc cng ly
truyn trong bnh vin nh Cytomegalovirus, HIV, Ebola, Influenza, Herpes v
Varicella-Zoster.
Nhiu nghin cu cho thy HBV, HIV, cm A ng vai tr ly nhim quan trng
trong mi trng bnh vin. Vim gan B c th ly nhim gia cc ngi bnh lm
sinh thit ni tnh mch trong cng mt ngy v cng mt phng. Ngi bnh ghp
tng l i tng c nguy c ly nhim cao. Nhng ngi bnh c HBsAg-, khng
HBc-, khng HBc+ v HBV DNA+ c coi l ngi lnh mang HBV v d c nguy
c bng pht vi rt vim gan B sau khi ghp tim. Ngoi ra nhim vi rt mt cch ngu
nhin do dung dch heparin c ln mu t ngi bnh mang HCV tim n cha xc
nh cng c th l ngun ly nhim vim gan C trong bnh vin.
Bn cnh vi rt vim gan, cc nh khoa hc Php cho thy 25% ngi bnh
hi sc cp cu b nhim mt loi vi rt gy bnh ng h hp trn c lin quan n
qut thng gi. Vi rt Herpes type-1 cng c pht hin thy trn bnh phm ca
ngi bnh th my vi t l kh cao (31%).
Vai tr gy bnh ca k sinh trng v nm
Mt s k sinh trng (Giardia lamblia) c th ly truyn d dng gia ngi
trng thnh v tr em. Nhiu loi nm v k sinh trng l cc sinh vt c hi v l
63

nguyn nhn nhim khun trong khi iu tr qu nhiu khng sinh v trong trng
hp suy gim min dch (Candida albicans, Aspergillus spp, Cryptococcus
neoformans,...). Cc loi Aspergillus spp thng gy nhim bn mi trng khng kh
v cc loi ny c bt ngun t bi v t, c bit l trong qu trnh xy dng
bnh vin. Tc gi Trng Anh Th v CS (2008) cho thy cc tc nhn gy NKBV
ti Bnh vin Bch Mai, ngoi cc vi khun Gram m thng gp th t l nhim
khun do nm Candida l kh cao (14,3%).
2.5. ng ly nhim khun bnh vin
C 3 ng ly truyn chnh trong c s y t l ly qua ng tip xc, ng
git bn v khng kh.
- ng tip xc: L ng ly nhim quan trng v ph bin nht trong
NKBV (chim 90% cc NKBV) v c chia lm hai loi khc nhau l ly nhim qua
ng tip xc trc tip (tip xc trc tip vi cc tc nhn gy bnh) v ly nhim
qua tip xc gin tip (tip xc vi vt trung gian cha tc nhn gy bnh).
- Ly nhim qua ng git bn: Khi cc tc nhn gy bnh cha trong cc
git nh bn ra khi ngi bnh ho, ht hi, ni chuyn bn vo kt mc mt, nim
mc mi, ming ca ngi tip xc. Cc tc nhn gy bnh truyn nhim c trong cc
git bn c th truyn bnh t ngi sang ngi trong mt khong cch ngn (<1
mt). Cc git bn c kch thc rt khc nhau, thng >5 m, c khi ln ti 30 m
hoc ln hn. Mt s tc nhn gy bnh qua ng git bn cng c th truyn qua
ng tip xc trc tip hoc tip xc gin tip.
- Ly qua ng khng kh: Xy ra do cc git nh cha tc nhn gy bnh c
kch thc < 5m. Cc git pht sinh ra khi ngi bnh ho hay ht hi, sau pht
tn vo trong khng kh v lu chuyn n mt khong cch xa, trong mt thi gian
di ty thuc vo cc yu t mi trng. Nhng bnh c kh nng ly truyn bng
ng khng kh nh lao phi, si, thy u, u ma, cm, quai b hoc cm, SARS
khi c lm th thut to kh dung ...
2.6. Ngun ly nhim khun bnh vin
C nhiu ngun ly nhim trong cc c s y t (CSYT) v d nh: Ngun ly
t mi trng (khng kh, nc, xy dng), bnh nhn, t cc hot ng khm v
cha bnh (th thut xm nhp v phu thut, dng c v thit b, ha tr liu...).
- T mi trng: Cc tc nhn gy bnh c th gp trong mi trng (khng kh,
nc, b mt vt dng xung quanh ngi bnh) nh nm, vi khun hoc cc loi vi rt
v cc k sinh trng.
- T ngi bnh: Cc yu t t ngi bnh lm thun li cho NKBV gm tui,
tnh trng sc khe v phng php iu tr c p dng. Nguy c c th c phn
loi theo 3 mc khc nhau: Nguy c mc thp, trung bnh v mc cao. Cc
ngi bnh c nguy c thp khi khng c du hiu bnh quan trng, h min dch
khng b nh hng v khng phi iu tr can thip. Tnh trng sc khe km, c
bit l tui cao cc p ng min dch t bo v min dch dch th b suy gim; tr
em c h thng p ng min dch cha hon chnh, sc chu ng stress km v th
sc khng vi vi khun yu nn xut hin mt nguy c ton thn. Ngoi ra ngi
bnh cao tui d mc bnh cn lin quan n tnh trng dinh dng km.
64

Hn na, ngi bnh nng dn n tnh trng tng trao i cht, kh nng min
dch suy yu, kh nng chng li cc VSV ngoi sinh gim v VSV ni sinh pht trin
mnh hn. Mt s yu t khc cng gp phn NKBV nh tnh trng ngi bnh khi
nhp vin (cp tnh hay khng cp tnh), thi gian nm vin, gii tnh, kh nng kh
nhim chn lc ca ng tiu ha v cc nguy c ny mang tnh c lp vi mi loi
nhim khun. Nguy c cao NKBV cng xy ra trn nhng ngi bnh thay tng, ung
th hoc nhim khun do suy gim min dch ngi nhim HIV, ngi bnh tn
thng h min dch, ngi bnh a chn thng hoc bng nng v ngi bnh
thng xuyn phi iu tr can thip.
- T hot ng chm sc v iu tr:
+ Do s dng cc dng c, thit b xm nhp:
+ Khi s dng cc thit b xm nhp nh t ni kh qun, my tr h hp, ni
soi thm d, dn lu sau m, t cathete tnh mch trung tm, dn lu tit niu..., tt
c cc iu tr can thip ph v c ch bo v t nhin ca c th l ngn cn s
xm nhp v tn cng ca cc VSV gy bnh v lun c xem l c nguy c cao. T
l cc NKBV lin quan n quy trnh iu tr xm nhp hoc dng c xm nhp chim
xp x 80% tng s nhim khun trong bnh vin.
+ Nhim khun lin quan n thit b xm nhp c cc tc gi m t nhiu
trong cc cng trnh nghin cu, v thi gian s dng cc thit b cng ko di th
nguy c i vi tt c cc nhim khun cng tng, c bit l nhim khun huyt v t
l t vong cao thng tp trung trn ngi bnh b nhim khun phi v nhim khun
huyt.
- T vic s dng khng sinh khng thch hp
+ Tnh trng khng thuc ca trc khun Gram (-) gy NKBV ngy cng gia
tng v ph bin tt c cc khoa iu tr trong bnh vin v tnh trng a khng
thng xy ra vi cc khng sinh thuc nhm quinolon, cephalosporin th h 3 v
aminoglycosid. S bng n ngy cng nhiu chng trc khun m xanh v
A.baumannii a khng khng sinh trong v ngoi khoa iu tr tch cc ang l vn
thng xuyn c cp ti ngy cng nhiu hu ht cc nghin cu gn y.
+ Khi s dng khng sinh khng hp l s lm tng chng khng thuc do c s
phi hp chn lc t nhin v thay i cc thnh phn gen khng thuc ca vi khun.
Khng khng sinh xut pht im t cc c s y t, sau lan rng ra cng ng v vi
khun khng thuc tr thnh cn nguyn ca khong 70% cc NKBV. T l mc v t
vong do NKBV c lin quan n vi khun khng thuc lm tng ng k cc loi
chi ph.
+ Ngn nga s bng pht v ly lan ca cc vi khun khng thuc s hn ch
c nh hng bt li v tn km. Vic qun l v s dng khng sinh thch hp
nh la chn thuc, liu dng trong qu trnh iu tr v gim st thng xuyn tnh
khng khng sinh s hn ch c tc khng thuc ca vi khun.
* Do cha tun th cc quy nh phng nga nhim khun ca NVYT nh tun
th v sinh tay cn thp, s dng chung gng tay, x l cc dng c y t dng li
c bit l cc dng c ni soi cha ng quy nh.
2.7. V sao nhim khun bnh vin cha gim
65

Nhn li, gn mt thp k qua, mc d c rt nhiu nhng n lc trong tt

c cc lnh vc t vic xy dng v ban hnh chnh sch KSNK, ti vic thit lp cc
h thng KSNK, o to v KSNK v tng cng thm cc phng tin, ha cht
phc v cho cng tc kim sat nhim khun. Tuy nhin, chng ta cn ghi nhn mt
iu l tnh trng nhim khun trong cc c s chm sc sc khe cha gim. Vy
nguyn nhn cua rtnh hnh trn l g. Di y c th nu mt s nguyn nhn chnh:
1. Cc yu t ni sinh (do chnh bn thn ngi bnh): Ngi bnh mc bnh
mn tnh, mc cc bnh tt lm suy gim kh nng phng v ca c th, nhng ngi
bnh dng thuc khng sinh ko di, tr s sinh non thng v ngi gi d b NKBV.
Cc vi sinh vt c tr trn da, cc hc t nhin ca c th ngi bnh c th gy
nhim khun c hi, c bit khi c th b gim sc khng.
2. Cc yu t ngoi sinh nh: V sinh mi trng, nc, khng kh, cht thi, qu
ti bnh vin, nm ghp, dng c y t, cc phu thut, cc can thip th thut xm
ln
3. Cc yu t lin quan n s tun th ca NVYT: Cc thc hnh theo hng
dn ca B Y t v ca T chc y t Th gii cha c tun th mc mong mun
nh:
V sinh tay tun th cn thp (thiu gim st, thiu iu kin v sinh tay)
- S dng chung gng tay sch cha ng quy nh (lm dng mang gng, dung
mt i gng tay cho nhiu ngi bnh..)
S dng khu trang cha ng quy nh (va lm dng va km hiu
qu)
- Cc n v kh khun, tit khun hot ng nhm chung cha p ng c
yu cu (hu ht ch c mt bung my tit khun, khng b tr mt chiu, nhn
vin lm cng vic kh khun - tit khun a phn l h l, cc hot ng kh khun,
tit khun cn th cng, thit b c v lc hu thiu cc tiu ch nh gi cht lng.
- T l mi tim an ton t cc tiu chun ra cn thp
- V sinh mi trng c tin b nhng vn cn tip tc ci thin (dng chung
gi lau nh, gi lau xong cha c x l ng cch, dung dch lm v sinh cha
ng nng ,..)
3. Hu qu ca NKBV
Nhim khun bnh vin dn n nhiu h ly cho ngi bnh v cho h thng y
t nh: Tng bin chng v t vong cho ngi bnh; ko di thi gian nm vin trung
bnh t 7 n 15 ngy; tng s dng khng sinh dn n tng s khng thuc ca vi
sinh vt v tng chi ph iu tr cho mt NKBV thng gp 2 n 4 ln so vi nhng
trng hp khng NKBV.
Theo bo co ca mt s nghin cu: Chi ph pht sinh do nhim khun huyt
bnh vin l $34.508 n $56.000 v do vim phi bnh vin l $5.800 n $40.000.
Ti Hoa K, hng nm c tnh c 2 triu ngi bnh b NKBV, lm tn thm 4,5 t
dollar vin ph. Vit Nam cha c nhng nghin cu quc gia nh gi chi ph ca
NKBV, mt nghin cu ti bnh vin Ch Ry cho thy NKBV lm ko di thi gian
nm vin 15 ngy vi chi ph trung bnh mi ngy l 192.000 VND v c tnh chi
ph pht sinh do NKBV vo khong 2.880.000 VND/ ngi bnh.
4. Cc vn bn quy phm php lut v/ lin quan n kim sot nhim khun
66

iu 62 Lut khm bnh cha bnh quy nh: C s khm bnh, cha bnh c
trch nhim thc hin cc bin php KSNK (Gim st, kh khun, tit khun, v sinh,
XLCT..); bo m c s vt cht cho KSNK; t vn v cc bin php KSNK; ngi
lm vic trong c s khm bnh, cha bnh v ngi bnh phi tun th cc quy nh
v KSNK.
Thng t 18/2009/TT-BYT ngy 14 thng 10 nm 2009 v hng dn t chc
thc hin cng tc KSNK trong cc c s khm bnh, cha bnh thay th cho cc
quy nh trc y ti Quy ch bnh vin (1997) cc quy ch lin quan n cng tc
KSNK. Theo B Y t c quy nh c th 10 nhim v chuyn mn v KSNK,
quy nh cc iu kin v t chc, v nhn lc, trang thit b v trch nhim ca cc
c nhn, b phn trong vic thc hin Thng t.
Quyt nh 43/2007/BYT-Q ban hnh Quy ch Qun l cht thi y t quy
nh cht thi rn y t c chia lm 5 nhm, bao gm: Cht thi ly nhim, Cht thi
ho hc nguy hi, Cht thi phng x, Bnh cha p sut, Cht thi thng thng. Quy
ch cng quy nh tiu chun cc dng c, bao b thu gom, vn chuyn cht thi rn
trong bnh vin; phn loi, thu gom, vn chuyn cht thi rn trong bnh vin; vn
chuyn cht thi rn ra ngoi c s y t ...
Quyt nh s 1040/Q-BYT ngy 30/3/2012, B Y t ban hnh K hoch
hnh ng quc gia tng cng cng tc KSNK trong cc c s KBCB giai on t
nay n 2015.
Chng trnh, ti liu o to Phng nga chun nm 2010.
Cc hng dn phng nga NKBV nh: Phng nhim khun vt m, phng
vim phi trn ngi bnh th my, phng nga chun, Tim an ton, Kh khun-tit
khun, Phng nhim khun huyt ngi bnh t catheter.
Kim tra bnh vin hng nm a cng tc KSNK thnh yu cu thng quy
i vi tt c cc bnh vin.
5. Cc bin php tng cng kim sot nhim khun bnh vin
5.1. V chnh sch: Xy dng chnh sch quc gia v tng cng cng tc KSNK.
Ban hnh cc hng dn quc gia v thc hnh KSNK trong cc c s khm cha
bnh. Xy dng cc chun nh gi cht lng thc hnh KSNK a vo ni dung
kim tra, thm nh cht lng bnh vin.
5.2. V t chc: B Y t (Cc qun l khm cha bnh) thnh lp t chuyn gia kim
sot NKBV t vn ban hnh K hoch quc gia v cc chnh sch, cc hng dn
quc gia v cng tc KSNK. i vi cc bnh vin: Thnh lp Hi ng KSNK;
Khoa/t KSNK v mng li KSNK lm u mi tham mu cho lnh o bnh
vin thc hin cc hng dn v quy nh v KSNK. Tng cng vai tr ca hi Kim
sot nhim khun: Duy tr hot ng ca cc Hi KSNK khu vc v chun b cc iu
kin thnh lp Hi KSNK Vit Nam.
5.3. V o to kim sot nhim khun bnh vin: o to chuyn khoa KSNK:
Cn b Y t Khoa (t) KSNK phi c o to chuyn khoa v thng xuyn cp
nht kin thc, k nng thc hnh KSNK. o to ph cp: thy thuc, nhn vin ca
c s khm bnh, cha bnh phi c o to chng trnh ph cp v KSNK bao
gm cc thc hnh v Phng nga chun v Phng nga da vo ng ly, cc
hng dn thc hnh phng nga NKBV theo c quan, v tr. o to KSNK trong cc
67

trng: B sung mn hc v phng v KSNK trong cc chng trnh o to bc s,

iu dng, h sinh v k thut vin. Trin khai Chng trnh o to v sinh bnh
vin cho h l v nhn vin v sinh bnh vin.
5.4. V t chc gim st nhim khun bnh vin: T chc gim st NKBV c c
s d liu v NKBV nh t l mc NKBV, tc nhn gy bnh, vi khun khng
thuc...)..Gim st l hot ng ch yu ca chng trnh kim sot NKBV v khoa
KSNK. Gim st NKBV c nh ngha l Vic thu thp c h thng, lin tc; vic
x l v phn tch nhng d kin cn thit nhm trin khai, lp k hoch, v ph bin
kp thi nhng d kin ny n nhng ngi cn c bit. Gim st NKBV l mt
trong nhng yu t quan trng ci thin tnh hnh NKBV. Nhn vin kim sot
NKBV thng phi dnh hn mt na thi gian tin hnh gim st. Gim st
NKBV s cung cp nhng d kin c ch nh gi tnh hnh NKBV: Nhn bit
nhng ngi bnh NKBV, xc nh v tr nhim khun, nhng yu t gp phn vo
nhim khun. T gip bnh vin c k hoch can thip v nh gi c hiu qu
ca nhng can thip ny. Gim st NKBV cn l tin cho vic thc hin cc nghin
cu v KSNK. Chng trnh gim st cng cn bao gm chng trnh kim sot khng
sinh. Cn a ra c nhng quy nh chnh sch s dng khng sinh. Cn hn ch
nhng hot ng tip th ca cc hng thuc trong bnh vin, c bit ti cc bnh vin
c o to.
5.5. V thc hnh kim sot nhim khun: T chc thc hin cc bin php Phng
nga chun, Phng nga b sung (da theo ng ly truyn bnh); T chc thc hin
cc hng dn v kim tra cc bin php thc hnh KSNK theo tc nhn, c quan v
b phn b nhim khun bnh vin.
5.6. Bo m cc iu kin cho cng tc KSNK: C b phn (n v) kh khun tit khun tp trung t tiu chun v c cc phng tin lm sch, c ra, kh
khun, tit khun v kho ng dng c sch v dng c v khun. C nh git thit k
mt chiu, trang b v phng tin nh my git, my sy, phng tin l (i)
vi, xe vn chuyn vi bn, sch; b (thng) cha ho cht kh khun ngm
vi nhim khun, t lu gi vi; x phng git, ha cht kh khun. C c s h
tng bo m x l an ton cht thi lng, cht thi rn v cht thi kh y t theo
Quy nh v qun l cht thi y t. C phng tin v sinh chuyn dng. Trng
hp c s khm bnh, cha bnh hp ng vi Cng ty cung cp dch v v sinh cng
nghip th hp ng phi xc nh r yu cu v trang thit b, ha cht, tiu chun v
sinh, quy trnh v sinh, o to nhn vin v sinh theo chng trnh ti liu ca B Y t
v kim tra nh gi cht lng. C s khm bnh, cha bnh phi bo m nhn lc
cho Khoa (t) KSNK hot ng. Ngoi nhn lc cho cc b phn nh kh khun, tit
khun, git l, b phn gim st nhim khun phi bo m ti thiu c 150 ging
bnh c 01 nhn lc chuyn trch gim st nhim khun.

68

TI LIU THAM KHO

1.
2.
3.
4.
5.
6.
7.
8.

9.
10.

11.

12.

13.

14.
15.

Nguyn Thanh H (2005), Gim st nhim khun bnh vin ti 6 tnh pha Nam.
Nguyn Vit Hng (2005). Tnh hnh nhim khun bnh vin ti cc bnh vin khu vc
pha Bc.
Trn Hu Luyn. Nhim khun bnh vin trn NB c phu thut
Phm c Mc v cng s (2005). Nhim khun bnh vin ti cc bnh vin trc
thuc B Y t nm 2005
L Anh Th. Nhim khun bnh vin trn cc bnh nhn c th my.
WHO. Patient Safety Curiculum Guideline. Multi-proesional Edition, 2011.
Ducel G et al. Prevention of hospital-acquired infections: a practical guide. 2nd ed.
Geneva, World Health Organization, 2002.
WHO guidelines on hand hygiene in health care. Geneva, World Health Organization,
2009:6-7
(http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf;
accessed 21 February 2011).
Allegranzi B et al. Burden of endemic health care-associated infections in developing
countries: systematic review and meta-analysis.Lancet, 2011, 377:228241.
Centers for Disease Control and Prevention campaign to prevent antimicrobial resistance
in
healthcare
settings.
Atlanta,
GA,
CDC,
2003
(http://www.cdc.gov/drugresistance/healthcare/; accessed 21 February 2011).
Institute for Healthcare Improvement (IHI). The Five Million Lives campaign. Boston,
MA, IHI, 2006 (http://www.ihi.org/IHI/Programs/Campaign/; accessed 21 February
2011).
Countries or areas committed to address health care-associated infection. Geneva, World
Health
Organization,
2011
(http://www.who.int/gpsc/statements/countries/
en/index.html; accessed 16 March 2011).
Centers for Disease Control and Prevention. Universal precautions for prevention of
transmission of HIV and other bloodborne infections. Atlanta, GA, CDC, 1996
(http://www.cdc.gov/niosh/topics/bbp/universal.h tml; accessed 21 February 2011).
Burke J. Infection control: a problem for patient safety. New England Journal of
Medicine, 2003, 348:651656.
National Noscomial Infections Surveillance. (2004), National Nosocomial Infections
Surveillance (NNIS) System Report,data summary from January 1992 through June
2004, Am J Infect Control, 32, pp. 470-485.

69

CU HI LNG GI
A. IN CM T THCH HP VO CH TRNG
Cu 1. Hon thin nh ngha v Nhim khun bnh vin:
Nhim khun bnh vin l nhim khun ngi bnh (A).. trong thi gian
iu tr ti bnh vin v nhim khun ny khng (B). cng nh khng
trong giai on (C) ti thi im nhp vin.
Cu 2. C 3 ng ly trong cc c s y t, bao gm:
A. Ly qua ng tip xc
B.
C.
B. CHN MT CU TR LI NG NHT
Cu 3. Thi gian thng xut hin NKBV sau nhp vin l:
A. Sau 12 gi k t khi nhp vin
B. Sau 24 gi k t khi nhp vin
C. Sau 48 gi k t khi nhp vin
D. Sau 72 gi k t khi nhp vin
Cu 4. Ngi bnh mc NKBV l do:
A. Yu t ni sinh (bn thn ngi bnh)
B. Ngoi sinh (mi trng)
C. Can thip th thut, phu thut
D. C 3 A, B v C
Cu 5. Nguyn nhn lm cho nhn vin y t b phi nhim l do:
A. Tai nn ri ro t kim tim v vt sc nhn nhim khun
B. Bn mu v dch t ngi bnh vo nim mc mt, mi, ming khi lm th
thut
C. Da tay khng lnh ln tip xc vi mu v dch sinh hc ca ngi bnh c
cha tc nhn gy bnh
D. C A, B, C
Cu 6. Cc NKBV thng gp l:
A. Vim phi,
B. Nhim khun huyt
C. Nhim khun tit niu
D. Nhim khun vt m
E. C A,B,C v D
Cu 7. Yu t lm tng nguy c nhim khun bnh vin:
A. Thit b v dng c y t s dng trn ngi bnh
B. Phu thut
C. S dng khng sinh
D. C A,B v C
Cu 8. Cng tc kim sot NKBV l nhim v ca:
A. Gim c bnh vin
B. Cc trng khoa
70

C. Cc iu dng trng
D. Tt c nhn vin y t
C. CHN CU TR LI NG SAI
TT

Ni dung

Cc vi khun gy nhim khun c hi thng c ngun gc

t c vi sinh vt ni sinh v vi sinh vt ngoi sinh

10
11

Cn b y t c th b mc nhim khun bnh vin

Quy ch cng tc khoa chng nhim khun trong quy ch
bnh vin c B Y t ban hnh theo Quyt nh s
1853/Q-BYT nm 1997 ang cn hiu lc thc hin

12

Quy nh v phng nga NKBV c a vo Lut khm

bnh cha bnh do Quc Hi thng qua nm 2009

13

Quy nh v KSNK c quy nh ti Thng t

18/2009/TT-BYT ca B Y t

14

lm tt cng tc KSNK, cc c s khm cha bnh phi

xy dng cc quy nh c th v KSNK ti n v mnh

15

Cng tc KSNK trong cc c s y t l mt ni dung trong

chng trnh An ton cho ngi bnh

P N
Cu 2:
Cu 3: C
B: Ly qua git bn
C: Ly qua khng kh

Cu 4. D

Cu 5. D

Cu 6. E

Cu 7. D

Cu 8. D

Cu 9. D

Cu 10. D

Cu 11. S

Cu 12.

Cu 13.

Cu 14. D

Cu 15.

Cu 1:
A: Mc phi
B: Hin din
C: bnh

71

Bi 6
PHNG NGA S C Y KHOA TRONG MI TRNG CHM SC
V S DNG TRANG THIT B VT T Y T
MC TIU
Sau hc bi ny hc vin c kh nng:
1. Trnh by c cc nguyn tc phng nga s c y khoa trong mi trng
chm sc v trong s dng trang thit b, vt t y t.
2. p dng c cc bin php Phng nga s c y khoa trong mi trng
chm sc v trong s dng trang thit b, vt t y t
NI DUNG
1. T VN
Mi trng chm sc trong cc c s y t cn t c cc tiu chun v an ton.
Cc c s y t cn nh gi, ci tin, v theo di hiu qu ca cc gii php an ton
mi trng trong khun kh chng trnh c yu cu v an ton cho bnh nhn
qui m c s. Cc hn ch trong mi trng chm sc v s dng trang thit b thng
l mt trong nhng nguyn do gc gy nn s c, chng hn nh t t, t ng, b gi
cht, bm thuc qu liu.
Theo tng kt cc bo co s c, tai nn t ng dn n t vong ng th hng
cao trong danh mc s c thng gp. Cc tai nn t ng chim khong 4,6% s c
theo bo co ca y ban an ton vo nm 2003. Chy n trong phng m cng l vn
u tin hng u cc c s cp cu v phu thut ti ch. Theo tp ch Cnh Bo
S C s 29, hn 27 triu cc cuc phu thut cho bnh nhn ngoi tr c thc hin
hng nm v ngi ta c tnh rng mi nm c khong 100 v chy n trong phu
thut.
Mc d cc nguyn do gc lin quan n mi trng chm sc c th ch l mt
trong nhiu yu t gp phn to nn s c, cc c s y t cn phi c nhng bc ch
ng nu ln cc nguyn do y cui cng tng cng s an ton cho bnh nhn. C
s y t cn xy dng v thc hin qui trnh bo co v iu tra cc s c lin quan n
mi trng chm sc v s dng trang thit b.
Cc s c lin quan n mi trng chm sc v s dng trang thit b c th bao gm:
- Cc s c v an ninh lin quan n bnh nhn, nhn vin, v nhng ngi c mt
hoc lin quan n c s vt cht.
- Vic trn ra ngoi cc nguyn vt liu nguy him v cht thi v nhng s vic
lin quan khc
- Cc vn v qun l an ton chy n, s thiu ht, v s ngng hot ng.
- Cc vn v qun l thit b, s ngng hot ng, v sai st ca ngi s dng
- Cc vn v qun l h thng tin ch cng cng, s ngng hot ng, v sai
st ca ngi s dng.
Cc s c ny c th lm cho bnh nhn v nhng ngi c mt b thng, lm
h hi c s vt cht, gy bnh ngh nghip v cc thng tn khc cho nhn vin y t.
2. NGUYN TC PHNG NGA
72

Cc tiu chun an ton trong qun l mi trng chm sc i hi cc c s y t

phi:
Thu thp thng tin v nhng thiu st v nhng c hi ci tin mi trng chm
sc. Thng tin ny gm nhng ri ro, s ngng hot ng, cc tai nn trong mi
trng lin quan n nhng lnh vc nh an ton, an ninh, cc vt liu nguy him,
qun l s khn cp, qun l trang thit b, an sinh, s lng ph, h thng cng trnh
cng cng v cc vn khc v mi trng.
Phn tch kp thi cc vn v mi trng c xc nh v trin khai cc bin
php gii quyt. Lnh o phi bo co v hin trng, xut, nhng bin php
thc hin; phi trin khai cc chnh sch v phng php thc hin an ton.
Xy dng k hoch qun l mi trng chm sc. Cc mc tiu, phm vi, vic thc
hin, v hiu qu ca tng k hoch qun l mi trng chm sc c thm nh
hng nm.
Xy dng v thc hin qui trnh theo di lin tc cc nguy c hin hu v nguy c
tim n trong k hoch qun l mi trng chm sc.
Xy dng cc hng dn nh gi, cc qui trnh gii quyt cc vn v mi
trng chm sc vi s tham gia ca i din t cc b phn iu tr, qun tr, v
h tr.
Thnh lp hi ng gm nhng ngi t nhiu lnh vc khc nhau hp t nht hai
thng mt ln a ra cc vn v mi trng chm sc.
Cc vn v mi trng chm sc c thng bo cho lnh o c s v (nhng)
ngi chu trch nhim cho cc hot ng ci tin.
Cc xut cn c xem xt v trin khai khi c th
Lnh o c s cn b nhim mt/nhiu ngi theo di, gim st v x l
nhng vn v mi trng ca c s.
Ngi c b nhim gim st mi trng c nhng nhim v sau:
- Thu thp thng tin lin tc v nhng thiu ht v nhng c hi ci tin trong mi
trng chm sc.
- Ph bin cc ngun thng tin, chng hn nh cc thng bo nguy him hoc cc
bo co s vic xy ra.
- Bo co nhng hn ch, kh khn, s ngng hot ng, v cc sai st ca ngi s
dng lin quan n vic qun l mi trng chm sc.
- xut, thc hin v bo co kt qu ca cc hot ng ci tin. xut ci tin
gii quyt nhng vn an ton mi trng trnh t nht mi nm mt ln n lnh
o c s da trn s theo di lin tc vic thc hin cc k hoch qun l mi
trng chm sc
- Tham gia vo vic gim st v bo co s c.
- Tham gia vo vic trin khai cc chnh sch an ton v cc phng thc thc hn
Cc tiu chun nhm gim s c lin quan n lnh vc s dng trang thit b bao gm
lp k hoch v chn la; bo tr, th nghim, v kim tra; o to v tp hun; phn
pht v lp t; v ngn nga ri ro lin quan n trang thit b v vt dng khc. Cc
cng on ca quy trnh ny gm c:
- Chn la.
- Cc chin lc bo tr.
- Vic thm nh c nh k.
- Hng dn v hun luyn.
3. CC BIN PHP PHNG NGA
73

3.1. Gim nguy c gy thng tn cho bnh nhn do b ng.

Nguy c t ng c th do mi trng chm sc hoc do bn thn ngi bnh.
Nguy c t ng c th do mi trng chm sc bao gm nhng thit k c s vt cht,
vt dng khng ph hp cho ngi bnh. Nguy c do bn thn ngi bnh bao gm c
tin s t ng trc , khim khuyt v cm gic v thnh gic, suy nhc thn kinh,
b xc ng suy nhc thng bng hoc vn ng, cc vn v c xng, cc bnh
mn tnh, ri lon tiu tin, cc vn v dinh dng, v vic s dng nhiu loi thuc
khc nhau.
- C s y t, c bit cc nh dng lo, cn thc hin chng trnh gim t ng v
nh gi hiu qu ca chng trnh. Chng trnh gim t ng bao gm cc chin
lc gim ri ro, thc hnh ti ch, s tham gia cu bnh nhn/gia nh trong hun
luyn, v vic thm nh mi trng iu tr.
- Thnh lp ban ngn nga t ng nh gi nhng bnh nhn mi v nguy c t
ng tim n; r sot thng xuyn cc c t ng, thm nh s tham gia, v tm
kim cc xu hng v m hnh mi; v trao i nhng pht hin mi vi cc
nhn vin khc.
- C s y t phi nh gi ban u v thng xuyn nguy c t ng ca bnh nhn v
c bin php ngn nga cc kh nng t ng tim n. Cn nh gi ton din bnh
nhn lc ban u khi bnh nhn nhp vin, xc nh mc nhn thc chung, sc
mnh ca c, s au n, v kh nng th hin hot ng hng ngy ca bnh
nhn. Cn nh gi nh k tng nguy c b ng ca bnh nhn, bao gm c nguy
c tim n.
- S dng cc k thut nh gi khc nhau, nh quan st hoc trao i vi c nhn
bnh nhn v gia nh nh gi ton din n mc c th.
- Nhn vin y t phi trao i vi gia nh bnh nhn v nhng ngi quan trng
khc vic nh gi ton din nguy c t ng. Thng bo cho cc thnh vin ca gia
nh bnh nhn cc yu t lm gia tng nguy c t ng
- Da vo nh gi, nhn vin y t a ra nhng kin ngh v thc hin phng php
ch ng ngn nga t ng trong k hoch v thc hin chm sc bnh nhn. Bt
c nguy c no c nhn din u cn c x l ngay.
- Nhn vin y t cn phi xem xt tt c thuc gm tt c thuc cp theo n, thuc
mua ti quy, v nhng th b sung m bnh nhn s dng. Lu h s tnh trng
d ng thuc v tin s lm dng thuc, k c lm dng thuc an thn v cc loi
thuc theo n khc. Vic thay i thuc gm c thuc gy nghin v cc liu
lng tng hoc gim i hi phi theo di ht sc cnh gic cc phn ng ph
mi c th xy ra. Mt loi thuc mi thm vo cc loi thuc bnh nhn ang
dng c th to nn cn chng mt, gy bun ng, hoc cc triu chng khc c
th a bnh nhn n nguy c t ng nhiu hn.
Thng xuyn ti nh gi v lu nhng biu hin khi bnh nhn tri qua gy
m
Mt s bin php ci tin mi trng gip gim t ng:
Lp t chung bo ng ti ging hoc thit k li h thng kim sot v kim
tra chung bo ng ti ging.
Lp t cc kho t ng cc phng phc v (nh phng git, v.v..)
Hn ch vic m ca s khi c nguy c.
Lp t chung bo ng cc li ra vo.
74

 B sung phn ngn nga t ng vo chng trnh hun luyn bnh nhn v gia nh
h.
Ci tin v chun ho h thng gi iu dng.
S dng ging thp cho nhng ngi c nguy c t ng.
3.2. Gim nguy c chy n trong phu thut
C s y t c th ngn nga nguy c chy n trong phu thut v qun l tt s chy
n nu n xy ra trong phng m bng cc bin php sau:
3.2.1. Xy dng k hoch, quy trnh chng chy n trong phu thut. K hoch cn
m bo cung cp cc nhn vin c thng tin ngn nga hoc qun l hiu qu
v chy phng m. K hoch a ra c nhng vn nh chui mnh lnh trong
tnh trng khn cp, xc nh r rng trch nhim ca cc thnh vin, v cc l trnh s
tn chnh v ph ngang qua bc tng la. Cn a ra cc hng dn c th v:
- Vic s tn
- Chi tit cc ti liu lu tr, thit b, dng c, hng d tr, v nhng th khc cn
c bo v kim tra sau v ho hon.
- Bn hng dn s dng oxy gim n ti thiu tp trung oxygen di cc drap
ph
- Hng dn qun l cc dung dch c cn dng trong st trng da.
3.2.2. Khuyn khch nhn vin y t hc tp v t rn luyn v phng chng chy n.
- Bo m nhn vin c tp hun v nhng ri ro chy n c bit trong khu phu
thut v cch x l ngn nga v dp tt chy n.
- Khuyn khch nhn vin tham gia vo tm hiu cc hot ng t hng dn, bao
gm:
o tng ngi cn ghi nh v tr bnh cha la, hp ko chung bo ng, ca
thot him, bnh th oxygen, v l trnh s tn kh thi;
o t hc kch hot h thng bo ng v ghi nhn chy n
o cho nhn vin cm bnh cha chy v s dng; hoc trnh by mt tnh
hung chng chy gi nh cho mt nhm nh (t 8 n 10 ngi) cho h
ng vai nh tht v sau tho lun.
- Nhn vin phi bit ni ct gi v bit s dng bnh cha chy, cng nh chun b
tinh thn n nhn ri ro cho tng trng hp phu thut m h tham gia.
3.2.3. Hun luyn tt c nhn vin qun l 3 yu t chy n.
Cc yu t c bn ca mt v chy lun lun hin din trong sut cuc phu
thut v hnh thnh chy n: kh, oxygen, v ngun nhit. Cc nh phu thut phi
kim sot c ngun nhit (cc dng c m nh thit b t in, dao m laser,
ngun nh sng quang hc, v cc tia cao p tnh in) bng cch dng cc bao che
hoc s dng cc phng tin d tr v ngn chng tip xc kh. Cc iu dng c
th gii hn s hin din ca nhng cht d chy (chng hn nh cc tc nhn
prepping, cn, thuc nhum, thuc m, v cc cht gy m) trnh bng pht ho
hon. Cc chuyn gia gy m c th gim n ti thiu vic to ra oxygen, c cha
nitrous oxide, v cc loi kh hi khc bng cch s dng cc k thut to nt chn .

75

Hun luyn nhn vin, phu thut vin v chuyn vin gy m v cch kim sot
ngun nhit v qun l kh: (1) Theo ng cc qui tc an ton ti khu vc c tia
laser v in, (2) Qun l kh bng cch cho thi gian chun b bnh nhn,
v (3) Xy dng bng hng dn gim n ti thiu vic tp trung oxygen di
tm vi ph.
Tin hnh cc kho hun luyn c bit v (1) vic s dng cc thit b chng chy
n, (2) cc phng php ng cch cu nn v thot him, v (3) s xc nh
ng v tr ca h thng ga y t, gi, v in, v cc nt iu khin, cng nh khi
no, u, v bng cch no tt cc h thng ny li.
Khng che ph bnh nhn cho n khi tt c cc vt chun b d chy u kh.
Trong phu thut hu hng, ngm ming gc hoc ming bt bin dng vi nhng
ci ng thng kh qun gim n ti thiu s r r O2 vo hu hng, v gi cho
chng lun m. Cn lm m cc ming bt bin, gc, v nt gc (v cc si dy ca
chng) chng khng bt la.

3.2.4. Tin hnh cc bui tp luyn lp i lp li. Nhn vin phng m phi tp luyn
chng chy n lp i lp li. Tp trung vo cc thit b chng chy n, cu nn
v thot him, khi no v bng cch no ng nt ngun gas y t, h thng
thng gi, v h thng phng m v nt kim sot, v h thng v chnh sch
bo ng ca c s lin lc vi s cu ho a phng. Thc hin v kim
tra cc cch thc bo m tt c cc thnh vin ca kp m c phn ng thch
hp trc s chy n trong phng m.
3.2.5. u tin ngn nga chy n. Nhc nh v thng tin v an ton chy n thng
xuyn. R sot li cc phng thc x l khn cp nh l mt phn ca vic
kim tra trc khi phu thut. Tt c mi ngi trong phng m, gi cho cc
yu t gy chy n khng tip xc ln nhau.
3.2.6. Bo m thit b c bo tr v s dng hp l. Tt c cc thit b m bng
in phi c nh lng v kim tra thng xuyn.
3.3. Gm nguy c t vong do b gi cht.
Nhng vt dng gi cht nh o lt hc o chn c bit i khi c dng
kim sot hoc bo v nhng ngi ln tui, m yu, khng bnh thng, hay lo u,
v thm ch b hn m. Mt s s c lin quan n nhng v b gi cht c th pht
xut t mt s yu t nh sau:
S dng nhng tay vn m khng c b phn bo v tay vn.
S dng thit b gi cht khng ng
S dng o khoc c cao.
S dng khng chnh xc thit b gi cht
Khng dng mt thit b iu khin hoc mt chung bo ng mt cch thch
hp.
C mt b iu khin hoc mt chung bo ng khng chu hot ng.
Cc t chc y t phi xem xt cc bin php sau y gim bt nguy c t vong
v b gi cht:
Thc hin chng trnh gim thiu n mc thp nht vic s dng cc vt dng
gi cht.
76

 Trin khai nhng phng thc qui nh cho vic p dng mt cch cht ch vt
gi cht.
Quan st lin tc bt c c nhn no ang b gi cht v l do ri lon hnh vi.
Nu cn gi cht bn trong lc ang v tr nm nga, phi bo m rng u ca
bn c thoi mi xoay qua xoay li v, khi c th, u ging c nng ln
gim n ti thiu nguy c v h hp.
Nu cn gi cht bn trong lc ang v tr nm sp, phi bo m rng ng i
ca khng kh lun lun khng b tc nghn (v d, ng che khun mt bn). Phi
bo m s dn n hai l phi ngi bnh khng b hn ch bi sc p qu nng
trn lng (c bit lu trng hp tr con, ngi gi, v nhng ngi bo ph).
Khng gi cht bn trn ging c nhng chn song ngang khp m khng an ton.
Bo m rng nhn vin y t c th nhanh chng ni lng v di tn ngi bnh
ang b gi cht khi c m chy hoc tai nn do thin tai. Cc bi tp hun thc
hnh phi bao gm tnh hung ny.
Bo m rng bnh nhn ang b gi cht khng c trong ngi hoc khng c th
n gn bt c vt sc bn hoc vt bt la no
Khuyn khch s dng cc liu php thay th cho vic gi cht. Tp hun cho
nhn vin s dng cc k thut can thip bng li ni gip ch ng ngn nga
v/hoc gim tnh hung khng hong tim n. Cc liu php thay th khc gm
chng trnh iu chnh hnh vi; thay i mi trng chm sc bng cch to nn
bu khng kh nh nh; gim ting n; i phng chuyn bnh nhn hung d
tim n xa khi ngi lm h kch ng; to c hi cho vic th gin, tp th dc,
v nhiu hot ng a dng khc.
3.4. Ci tin an ton trong vic dng bm truyn dch
Thiu kim sot mc chy v khng gii hn dch truyn v/hoc thuc vo
c th bnh nhn s dn n t vong hoc thng tn nghim trng. Cn bo m tt
c cc bm truyn dch tnh mch thng thng v bm truyn dch tnh mch lu
thng thng sut. Cn bo v bnh nhn khi nhng hu qu bt li tim n lin quan
n vic s dng bm truyn dch thng thng v bm truyn dch bng cch yu cu
kim sot cc dng dch truyn t do bn trong c th.
Khi s dng bm truyn dch, cn h thng khng bao gi cho php dch truyn
chy vo bnh nhn m khng chy qua mt thit b bo v dng chy trc . Do
, thit b bo v dng chy phi c gn vo bn trong dng c, lun lun trong
tnh trng s dng a dch truyn t bm tim vo c th bnh nhn. Nu thit b
bo v ch l dng c gn thm vo, c th c hin tng s dng bm truyn dch v
b iu khin khng c dng c bo v dng chy, t c th to ra dng chy t do
v dn n thng tn hoc t vong. V vy, thit b bo v dng truyn dch phi nm
bn trong ca chnh bm truyn hoc b iu khin lun lun trong tnh trng s dng
trong ci bm. Mt dng c bo v gn thm vo khng nm bn trong bm truyn
dch hoc b iu khin l khng p ng yu cu.
kim tra xem bm truyn dch c thit b bo v dng chy hay khng, tt
n nhng gi cho b phn truyn vn truyn v ti trong thit b. Trong khi tt c
cc ci kp ca h thng bm m v bnh cha dch truyn c gi trn cao n mc
c th c, phi khng c cht dch truyn no chy ra ngoi b phn ny khi n treo
thng ng. Sau , tho ri b phn truyn ra khi thit b (vi cc ci kp vn m)
77

v mt ln na kim tra rng hon ton khng c dch truyn no chy ra khi b phn
truyn.
TI LIU THAM KHO
1. Mc. Carthy P.M., Gaucher K. A.: Home study program: Fire in the OR: Developing a fire
safety plan. AORN Journal 79: 588 600, Mar. 2004.

CU HI LNG GI
A. CHN CM T THCH HP IN VO CH TRNG
Cu 1. Cc tiu chun an ton trong qun l mi trng chm sc i hi cc c s y
t phi thu thp (1) v nhng ..(2) v nhng c hi . mi
trng chm sc.
Cu 2. Ngi c b nhim gim st mi trng c nhim v thu thp thng tin
..(1) v nhng .(2) v nhng c hi (3) trong mi trng
chm sc,
(4) cc ngun thng tin, chng hn nh cc thng bo nguy him
hoc cc bo co s vic xy ra.
B. CHN 01 HOC NHIU CU TR LI NG NHT
Cu 3. Cc bin php ci tin mi trng gim t ng:
a. Lp t chung bo ng ti ging, cc li ra vo.
b. M ca s
c. S dng ging thp cho nhng ngi c nguy c t ng.
d. Lau sn sch
Cu 4. Nu cn gi cht bn trong lc ang v tr nm nga, phi bo m:
a. u ca bn c thoi mi xoay qua xoay li
b. u ca bn phi c nh cht
c. u ging thp
d. u ging c nng ln gim n ti thiu nguy c v h hp
Cu 5. Nhm gim nguy c chy n trong khi thc hin phu thut, nhn vin phi:
a. Che ph bnh nhn ngay, khng ch n khi tt c cc vt chun b d chy
u kh.
b. Theo ng cc qui tc an ton ti khu vc c tia laser v in
c. Thi gian chun b bnh nhn qun l kh
d. Xy dng bng hng dn gim ti thiu vic tch t oxygen di vi
ph.
Cu 6. Khi s dng bm truyn dch, cn phi ch
a. Dch truyn chy vo bnh nhn phi qua thit b bo v dng chy
b. Thit b bo v dng chy phi c gn vo bn trong dng c, lun
trong tnh trng s dng
c. Gn thm pha ngoi thit b bo v bo v dng chy
78

Cu 7. Nhng liu php thay th vic gi cht bao gm:

a. Tp hun cho nhn vin s dng cc k thut can thip bng li ni
b. Thay i mi trng chm sc bng cch to nn bu khng kh nh nh
c. Tng m thanh, ting n bnh nhn b xao lng
d. Xp bnh nhn c c tnh hung hn gn ngi d kch ng
e. To c hi cho vic th gin, tp th dc, v nhiu hot ng a dng khc.
C. CU HI M
Cu 8. Nu cc s c thng gp lin quan n mi trng chm sc v s dng
trang thit b.
Cu 9. Theo Anh/ch, bnh vin cn phi lm g gim nguy c lm bnh nhn t
ng?
Cu 10. Theo Anh/ch, bnh vin cn phi lm g gim nguy c chy n trong bnh
vin
P N
Cu 1: 1: thng tin;

2: thiu st;

3: ci tin

Cu 2: 1: lin tc;

2: thiu ht;

3: ci tin;

4: ph bin

Cu 3: a,c,d
Cu 4: a,d
Cu 5: b,c,d
Cu 6: a,b
Cu 7: a,b,e

79

PH LC 1
B Y T

CNG HA X HI CH NGHA VIT NAM

c lp - T do - Hnh phc

S: 19 /2013/TT-BYT

H Ni, ngy 12 thng 7 nm 2013

THNG T

Hng dn thc hin qun l cht lng

dch v khm bnh, cha bnh ti bnh vin
Cn c Ngh nh s 63/2012/N-CP ngy 31 thng 8 nm 2012 ca Chnh ph
quy nh chc nng, nhim v, quyn hn v c cu t chc ca B Y t;
B Y t ban hnh Thng t hng dn thc hin qun l cht lng dch v
khm bnh, cha bnh ti bnh vin.
Chng I
QUY NH CHUNG
iu 1. Phm vi iu chnh
Thng t ny hng dn vic qun l cht lng dch v khm bnh, cha bnh
ti bnh vin (sau y gi tt l qun l cht lng bnh vin), bao gm:
1. Ni dung trin khai qun l cht lng bnh vin.
2. H thng t chc qun l cht lng bnh vin.
3. Trch nhim thc hin qun l cht lng bnh vin.
iu 2. Nguyn tc t chc thc hin qun l cht lng
1. Ly ngi bnh lm trung tm.
2. Vic bo m v ci tin cht lng l nhim v trng tm, xuyn sut ca
bnh vin, c tin hnh thng xuyn, lin tc v n nh.
3. Cc quyt nh lin quan n hot ng qun l cht lng trong bnh vin
da trn c s php lut, c s khoa hc vi cc bng chng c th v p ng nhu
cu thc tin nng cao cht lng ca bnh vin.
4. Gim c bnh vin chu trch nhim v cht lng bnh vin. Tt c cn b,
cng chc, vin chc, ngi lao ng (gi chung l nhn vin y t) trong bnh vin c
trch nhim tham gia hot ng qun l cht lng.
Chng II
NI DUNG TRIN KHAI QUN L CHT LNG
TRONG BNH VIN
iu 3. Xy dng k hoch, chng trnh bo m v ci tin cht lng
trong bnh vin
80

1. Bnh vin xy dng, ban hnh, ph bin mc tiu cht lng nhn vin y
t, ngi bnh v cng ng c bit. Mc tiu cht lng ph hp vi chnh sch,
php lut lin quan n cht lng v ngun lc ca bnh vin.
2. Bnh vin xy dng, ph duyt k hoch v lp chng trnh bo m, ci
tin cht lng thng qua vic xc nh cc vn u tin. Ni dung ca k hoch
cht lng c lng ghp vo k hoch hot ng hng nm v 5 nm, ph hp vi
ngun lc ca bnh vin.
iu 4. Duy tr quy chun k thut quc gia v bnh vin
1. Bnh vin bo m cc iu kin c cp giy php hot ng theo l
trnh quy nh ti Ngh nh s 87/2011/N-CP ngy 27 thng 9 nm 2011 ca Chnh
ph.
2. Bnh vin c cp giy php c trch nhim tip tc duy tr cc hot
ng bo m p ng quy chun k thut quc gia v cc iu kin khc do B Y
t quy nh.
iu 5. Xy dng ch s cht lng, c s d liu v o lng cht lng
bnh vin
1. Xy dng b ch s cht lng bnh vin da trn hng dn ca B Y t v
tham kho cc b ch s cht lng bnh vin trong nc hoc nc ngoi.
2. Thc hin o lng ch s cht lng trong bnh vin.
3. T chc thu thp, qun l, lu tr, khai thc v s dng d liu lin quan n
cht lng bnh vin.
4. Lng ghp bo co cht lng vo bo co hot ng chung ca bnh vin.
5. ng dng cng ngh thng tin xy dng c s d liu, phn tch, x l
thng tin lin quan n qun l cht lng bnh vin.
iu 6. T chc trin khai cc quy nh, hng dn chuyn mn trong
khm bnh, cha bnh
1. T chc trin khai thc hin cc quy nh, hng dn chuyn mn do B Y
t v bnh vin ban hnh, bao gm hng dn chn on v iu tr, hng dn quy
trnh k thut, hng dn quy trnh chm sc v cc vn bn hng dn chuyn mn
khc.
2. T chc trin khai thc hin kim nh cht lng nhm nh gi vic thc
hin cc quy nh, hng dn chuyn mn ca bnh vin; tin hnh phn tch c h
thng cht lng chn on, iu tr, chm sc ngi bnh, bao gm cc quy trnh k
thut lm sng, cn lm sng s dng trong chn on, iu tr, chm sc ngi bnh.
iu 7. Trin khai cc bin php bo m an ton ngi bnh v nhn vin
y t
1. Thit lp chng trnh v xy dng cc quy nh c th bo m an ton
ngi bnh v nhn vin y t vi cc ni dung ch yu sau:
a) Xc nh chnh xc ngi bnh, trnh nhm ln khi cung cp dch v;
b) An ton phu thut, th thut;
c) An ton trong s dng thuc;
d) Phng v kim sot nhim khun bnh vin;
81

) Phng nga ri ro, sai st do trao i, truyn t thng tin sai lch gia nhn
vin y t;
e) Phng nga ngi bnh b ng;
g) An ton trong s dng trang thit b y t.
2. Bo m mi trng lm vic an ton cho ngi bnh, khch thm v nhn
vin y t; trnh tai nn, ri ro, phi nhim ngh nghip.
3. Thit lp h thng thu thp, bo co sai st chuyn mn, s c y khoa ti cc
khoa lm sng v ton bnh vin, bao gm bo co bt buc v t nguyn.
4. Xy dng quy trnh nh gi sai st chuyn mn, s c y khoa xc nh
nguyn nhn gc, nguyn nhn c tnh h thng v nguyn nhn ch quan ca nhn
vin y t; nh gi cc ri ro tim n c th xy ra.
5. X l sai st chuyn mn, s c y khoa v c cc hnh ng khc phc i
vi nguyn nhn gc, nguyn nhn c tnh h thng v nguyn nhn ch quan gim
thiu sai st, s c v phng nga ri ro.
iu 8. p dng b tiu chun qun l cht lng bnh vin
1. Bnh vin cn c vo cc b tiu ch, tiu chun qun l cht lng do B Y
t ban hnh hoc tha nhn la chn b tiu ch, tiu chun ph hp v trin khai
p dng ti bnh vin.
2. Quy trnh trin khai p dng b tiu ch, tiu chun qun l cht lng c
thc hin theo hng dn ca c quan ban hnh b tiu ch, tiu chun hoc t chc
chng nhn cht lng.
3. Sau khi bnh vin c cp giy chng nhn cht lng cn tip tc duy tr
v ci tin cht lng.
iu 9. nh gi cht lng bnh vin
1. Trin khai thc hin nh gi cht lng ni b ca bnh vin da trn b
tiu ch, tiu chun qun l cht lng do B Y t ban hnh hoc tha nhn.
2. nh gi hiu qu p dng cc tiu ch, tiu chun, m hnh, phng php v
qun l cht lng ti bnh vin a ra quyt nh la chn tiu ch, tiu chun, m
hnh, phng php ph hp.
3. Bnh vin thc hin ly kin thm d v nh gi s hi lng ca ngi
bnh, ngi nh ngi bnh, nhn vin y t thng xuyn t nht l 03 thng mt ln,
lm c s cho vic ci tin nng cao cht lng phc v ngi bnh v s hi lng ca
nhn vin y t.
4. Bnh vin xy dng cc bo co cht lng v t cng b bo co cht lng
theo hng dn ca B Y t.
5. Cc c qun l tin hnh nh gi cht lng bnh vin hoc thm nh bo
co cht lng da trn b tiu ch, tiu chun qun l cht lng do B Y t ban hnh
hoc tha nhn theo nh k hng nm hoc t xut.
Chng III
H THNG QUN L CHT LNG TRONG BNH VIN
iu 10. T chc h thng qun l cht lng trong bnh vin
1. H thng qun l cht lng trong bnh vin gm: hi ng qun l cht
lng bnh vin do gim c bnh vin lm ch tch v ph gim c ph trch
82

chuyn mn lm ph ch tch; phng/t qun l cht lng; nhn vin chuyn trch v
qun l cht lng; mng li qun l cht lng ph hp vi quy m ca bnh vin.
2. Bnh vin hng c bit v bnh vin a khoa hng I thnh lp phng qun l
cht lng; cc bnh vin khc ty theo quy m, iu kin v nhu cu ca tng bnh
vin quyt nh thnh lp phng hoc t qun l cht lng. Phng/t qun l cht
lng phi hp cht ch vi cc khoa, phng chc nng thc hin nhim v qun l
cht lng bnh vin.
3. Mng li qun l cht lng bnh vin: c thit lp t cp bnh vin n
cc khoa, phng, n v trong bnh vin, do phng/t qun l cht lng lm u mi
iu phi cc hot ng.
4. Hot ng ca hi ng qun l cht lng bnh vin:
a) Ch tch hi ng phn cng nhim v cho cc thnh vin v xy dng quy
ch hot ng ca hi ng qun l cht lng bnh vin;
b) Ch tch hi ng thit lp h thng qun l cht lng, xy dng v ban
hnh cc vn bn v qun l cht lng trong bnh vin;
c) Hi ng qun l cht lng bnh vin t chc cc cuc hp nh k v t
xut nhm h tr, gim st v a ra cc khuyn ngh lin quan n qun l cht
lng.
5. T chc v nhim v ca hi ng qun l cht lng; phng/t qun l cht
lng; nhim v v quyn hn ca trng phng/t trng qun l cht lng v nhn
vin, thnh vin mng li qun l cht lng thc hin theo hng dn ti cc iu
11, iu 12, iu 13, iu 14, iu 15 ca Thng t ny.
iu 11. T chc v nhim v ca hi ng qun l cht lng
1. T chc:
Hi ng qun l cht lng trong bnh vin do gim c bnh vin ban hnh
quyt nh thnh lp, quy ch v duy tr hot ng; th k thng trc l trng
phng/t trng qun l cht lng bnh vin. S lng thnh vin hi ng ty thuc
vo quy m ca bnh vin, gm i din cc khoa, phng c lin quan n hot ng
ci tin cht lng bnh vin v an ton ngi bnh.
2. Nhim v:
a) Pht hin cc vn cht lng, cc nguy c tim n i vi an ton ngi
bnh, xc nh cc hot ng u tin v xut cc n bo m, ci tin cht lng
v an ton ngi bnh vi gim c bnh vin;
b) Gip cho gim c trin khai b tiu ch, tiu chun qun l cht lng do
B Y t ban hnh hoc tha nhn, ph hp vi iu kin ca bnh vin;
c) Tham gia t chc thc hin vic p dng b tiu ch, tiu chun cht lng,
nh gi ni b cht lng bnh vin v thng qua bo co cht lng bnh vin;
d) H tr k thut cho cc khoa, phng trin khai cc hot ng ca cc
n bo m, ci tin cht lng do gim c bnh vin ph duyt.
iu 12. T chc v nhim v ca phng/t qun l cht lng
1. T chc:
a) Phng qun l cht lng bnh vin c trng phng, ph trng phng v
cc nhn vin, ty thuc quy m bnh vin v do gim c quyt nh;
b) T qun l cht lng bnh vin do gim c trc tip ph trch hoc l b
phn ca mt phng chc nng do lnh o phng ph trch.
83

2. Nhim v:
L n v u mi trin khai v tham mu cho gim c, hi ng qun l cht
lng bnh vin v cng tc qun l cht lng bnh vin:
a) Xy dng k hoch v ni dung hot ng qun l cht lng trong bnh
vin trnh gim c ph duyt;
b) T chc thc hin, theo di, gim st, nh gi, bo co, phi hp, h tr
vic trin khai cc hot ng v qun l cht lng v cc n bo m, ci tin cht
lng ti cc khoa phng;
c) Lm u mi thit lp h thng qun l sai st, s c bao gm pht hin,
tng hp, phn tch, bo co v nghin cu, xut gii php khc phc;
d) Lm u mi phi hp vi cc khoa, phng gii quyt cc n th, khiu
ni, t co v cc vn lin quan n hi lng ngi bnh;
) Thu thp, tng hp, phn tch d liu, qun l v bo mt thng tin lin quan
n cht lng bnh vin. Phi hp vi b phn thng k, tin hc ca bnh vin tin
hnh o lng ch s cht lng bnh vin;
e) Trin khai hoc phi hp t chc o to, hun luyn, tp hun, bi dng v
qun l cht lng;
g) T chc nh gi cht lng ni b ca bnh vin da trn cc b tiu ch,
tiu chun qun l cht lng do B Y t ban hnh hoc tha nhn;
h) Thc hin nh gi vic tun th cc quy nh v hng dn chuyn mn ca
B Y t;
i) Xy dng v trin khai thc hin chng trnh an ton ngi bnh.
iu 13. Nhim v v quyn hn ca trng phng/t trng qun l cht
lng
1. Nhim v:
a) T chc thc hin y cc nhim v ca phng/t qun l cht lng v
chu trch nhim v cc hot ng ca phng/t qun l cht lng.
b) Tng kt, bo co hot ng ca phng/t qun l cht lng, kt qu cng
tc ci tin cht lng bnh vin v an ton ngi bnh;
c) H tr cc nhm cht lng ti cc khoa, phng thc hin cc n bo
m, ci tin cht lng;
d) Tham gia nh gi cht lng bnh vin;
) Lm th k ca hi ng qun l cht lng bnh vin.
2. Quyn hn:
a) Kim tra v yu cu cc khoa, phng, c nhn thc hin ng k hoch qun
l cht lng ca bnh vin;
b) xut vi gim c vic khen thng, k lut i vi cc c nhn v tp
th trong thc hin nhim v qun l cht lng.
iu 14. Nhim v v quyn hn ca nhn vin phng/t qun l cht
lng bnh vin
1. Nhim v:
a) Thc hin cc nhim v theo bn m t v tr vic lm ca phng/t qun l
cht lng v cc cng vic khc theo s phn cng ca trng phng/t trng qun
l cht lng bnh vin;
b) Thu thp, phn tch, qun l, bo mt cc d liu lin quan n qun l cht
lng bnh vin trong lnh vc c phn cng;
84

c) H tr cc nhm cht lng ti cc khoa, phng thc hin cc n bo

m, ci tin cht lng;
d) Tham gia o to, hun luyn, tp hun, bi dng v nh gi cht lng
bnh vin.
2. Quyn hn:
a) Kim tra, gim st cc hot ng qun l cht lng bnh vin ca cc khoa,
phng;
b) n c cc c nhn, n v thc hin cc bin php khc phc sau kim tra,
gim st;
c) xut khen thng i vi cc n v, c nhn thc hin tt cng tc qun
l cht lng.
iu 15. Cc thnh vin mng li qun l cht lng
1. Mi khoa, phng, n v (gi tt l n v) ca bnh vin c t nht mt nhn
vin kim nhim tham gia mng li qun l cht lng.
2. Nhim v ca cc thnh vin mng li qun l cht lng ti n v:
a) Lm u mi gip lnh o n v trin khai, thc hin, theo di cc hot
ng lin quan n qun l cht lng bnh vin;
b) Thc hin cc k hoch hot ng ca mng li qun l cht lng bnh
vin ti n v;
c) Tham gia kim tra, nh gi cht lng bnh vin theo phn cng ca Hi
ng qun l cht lng bnh vin.
Chng IV
TRCH NHIM THC HIN QUN L CHT LNG BNH VIN
iu 16. Trch nhim ca gim c bnh vin
1. Ch o, ph bin, qun trit ni dung Thng t ny ti ton th cn b, cng
chc, vin chc trong bnh vin.
2. Thit lp h thng t chc qun l cht lng trong bnh vin theo hng
dn ti cc iu 10, iu 11, iu 12, iu 15 ca Thng t ny.
3. Trin khai, p dng cc b tiu ch, tiu chun qun l cht lng do B Y t
ban hnh hoc tha nhn.
4. Gim c bnh vin b tr kinh ph cho cc hot ng qun l cht lng:
a) Trin khai cc hot ng p dng cc b tiu ch, tiu chun qun l cht
lng do B Y t ban hnh hoc tha nhn;
b) Duy tr v ci tin cht lng;
c) T chc v c cn b o to, hun luyn, tp hun, bi dng v qun l
cht lng;
d) Khen thng cho tp th, c nhn xut sc trong hot ng qun l cht
lng bnh vin;
) Hp ng t vn, nh gi, chng nhn cht lng.
e) Cc hot ng nng cao cht lng bnh vin v an ton ngi bnh khc
ty theo nhu cu bnh vin.
5. Bo m ngun nhn lc v o to v qun l cht lng, bao gm:

85

a) u t ngun nhn lc cho qun l cht lng, thnh lp phng hoc t qun
l cht lng, phn cng nhn vin y t chuyn trch, kim nhim v qun l cht
lng;
b) T chc hoc c nhn vin y t tham gia cc kho o to, hun luyn, tp
hun, bi dng v qun l cht lng do cc c quan, t chc trong v ngoi nc
thc hin;
c) C nhn vin y t chuyn trch v qun l cht lng bnh vin tham gia cc
kha o to chuyn su v qun l cht lng bnh vin.
6. Bo m iu kin v trang thit b v phng tin:
a) Trang b phng tin phn tch, x l, lu tr d liu qun l cht lng;
b) Xy dng cc cng c v vn bn hng dn v qun l cht lng.
7. Ch o nghin cu khoa hc, kim tra, gim st thc hin cng tc qun l
cht lng.
8. Tham gia cc lp o to, hun luyn, tp hun, bi dng v qun l cht
lng do cc c quan, t chc trong v ngoi nc thc hin.
iu 17. Trch nhim cc trng phng chc nng ca bnh vin
1. Ph bin ni dung Thng t ny ti ton th nhn vin trong phng.
2. Xy dng mc tiu cht lng, lng ghp cc hot ng qun l cht lng
vo k hoch hot ng ca phng v lnh vc c phn cng ph trch.
3. Trin khai v phi hp vi khoa, phng khc p dng cc tiu ch, tiu chun
qun l cht lng do B Y t ban hnh hoc tha nhn ti phng v lnh vc c
phn cng ph trch.
4. Phi hp vi phng/t qun l cht lng xy dng k hoch v trin khai
cc hot ng bo m v ci tin cht lng bnh vin.
5. Tham gia cc lp o to, hun luyn, tp hun, bi dng v qun l cht
lng do cc c quan, t chc trong v ngoi nc thc hin.
6. Tham gia nh gi cht lng bnh vin.
iu 18. Trch nhim ca cc trng khoa
1. Ph bin ni dung Thng t ny ti ton th nhn vin trong khoa.
2. Xc nh cc vn cht lng cn u tin ca khoa ch ng ci tin
hoc xut vi hi ng qun l cht lng bnh vin.
3. Trin khai v phi hp vi khoa, phng, n v khc nghin cu, p dng cc
tiu ch, tiu chun qun l cht lng do B Y t ban hnh hoc tha nhn ti khoa
c phn cng ph trch.
4. Phn cng nhn vin trin khai cc hot ng bo m v ci tin cht lng
v nh gi kt qu thc hin.
5. Bo co kt qu hot ng bo m v ci tin cht lng cho hi ng qun
l cht lng bnh vin.
6. Phi hp vi phng/t qun l cht lng v cc n v thc hin n bo
m, ci tin cht lng c lin quan.
7. Tham gia cc lp o to, hun luyn, tp hun, bi dng v qun l cht
lng do cc c quan, t chc trong v ngoi nc thc hin.
8. Tham gia nh gi cht lng bnh vin.
iu 19. Trch nhim ca cc nhn vin y t trong bnh vin
86

1. Tham gia cc chng trnh, k hoch, hot ng ci tin cht lng ty theo
chc trch, nhim v ca mnh.
2. Tham gia cc lp o to, hun luyn, tp hun, bi dng v qun l cht
lng do cc c quan, t chc trong v ngoi nc thc hin.
Chng V
IU KHON THI HNH
iu 20. L trnh thc hin cng tc qun l cht lng bnh vin
1. Giai on I: 2013-2015
a) Hon thin h thng t chc qun l cht lng ti cc S Y t, Y t ngnh
v cc bnh vin;
b) Mi bnh vin t chc hoc c nhn vin tham d cc kha o to, hun
luyn, tp hun, bi dng v qun l cht lng do cc c quan, t chc trong v
ngoi nc thc hin;
c) Bnh vin p dng b tiu ch, tiu chun qun l cht lng do B Y t ban
hnh hoc tha nhn t nh gi v ci tin cht lng;
d) Khuyn khch cc bnh vin p dng th im cc m hnh, phng php
cht lng v cc b tiu chun qun l cht lng.
2. Giai on II: 2016 - 2018
a) Bnh vin nh gi hiu qu vic p dng cc b tiu ch, tiu chun, ch s,
m hnh, phng php cht lng;
b) o to cn b chuyn trch qun l cht lng bnh vin;
c) T nguyn ng k vi t chc chng nhn cht lng nh gi cht
lng bnh vin;
d) Cc c quan qun l tin hnh nh gi, thm nh v cng nhn cht lng
bnh vin.
3. Giai on III: Sau nm 2018
Bnh vin tip tc p dng cc b tiu ch, tiu chun, ch s, m hnh, phng
php cht lng v ng k chng nhn cht lng theo hng dn ca B Y t v cc
t chc chng nhn cht lng c lp.
iu 21. Hiu lc thi hnh
Thng t ny c hiu lc t ngy 15 thng 9 nm 2013.
iu 22. T chc thc hin
1. Cc Qun l Khm, cha bnh c trch nhim:
a) Lm n v u mi t chc trin khai thc hin, kim tra nh gi vic thc
hin Thng t ny ca cc bnh vin trc thuc v cc a phng;
b) Ch tr hoc phi hp vi cc n v lin quan xy dng quy chun, quy
nh, tiu ch, tiu chun, ch s v cht lng bnh vin;
c) Thc hin cc nhim v khc lin quan n qun l cht lng bnh vin
theo s phn cng ca B trng B Y t.
2. Cc V, Cc c lin quan, ty theo chc nng nhim v c phn cng
tham gia ch o v trin khai cc hot ng qun l cht lng bnh vin.
3. S Y t tnh, thnh ph trc thuc Trung ng; Y t ngnh c trch nhim:
87

a) Phn cng mt lnh o S Y t/Y t ngnh; mt lnh o phng nghip v y

v mt chuyn vin ph trch cng tc qun l cht lng ca cc bnh vin do S Y
t, Y t ngnh qun l;
b) Xy dng k hoch nng cao cht lng bnh vin cho h thng cc bnh
vin ca tnh/ngnh v trnh cp c thm quyn ph duyt;
c) Ph bin, ch o, kim tra v nh gi vic thc hin Thng t ti cc bnh
vin trc thuc; bo co v B Y t nh k hng nm v theo yu cu.
Trong qu trnh thc hin nu c kh khn, vng mc, cc n v phn nh v
Cc Qun l Khm, cha bnh - B Y t c hng dn, gii p hoc xem xt
gii quyt./.
Ni nhn:
- Vn phng Chnh Ph (P.Cng bo, Cng
TTTCP);
- B T php (Cc Kim tra vn bn QPPL);
- Cc Th trng ( bit v ch o);
- Cc V, Cc, Tng cc, Vn phng B, Thanh tra
B;
- S Y t cc tnh, thnh ph trc thuc Trung ng;
- Cc bnh vin, vin c ging bnh trc thuc B
Y t;
- Y t cc ngnh;
- Cng thng tin in t B Y t; Website Cc
QLKCB;
- Lu: VT, PC, KCB.

B TRNG

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