Estimating hospital deaths due to medical errors - Preventability is in the eye of the reviewer
Estimating hospital deaths due to medical errors - Preventability is in the eye of the reviewer
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DOI：
10.1001/jama.286.4.415
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发表时间：
2001-07-25
影响因子：
120.7
通讯作者：
Hofer, TP
中科院分区：
文献类型：
--
作者：
Hayward, RA;Hofer, TP
使用医生隐性审查的研究表明，美国医院因医疗差错而死亡的人数非常高。然而，有些人质疑这些估计的有效性。目的为了检查审查员对医疗差错的评级的可靠性，以及如果护理是最佳的，就立即和短期生存的概率而言，被描述为“通过更好的护理可以预防”的死亡的含义。设计回顾性隐式审查1995- 1996年的医疗记录。受过训练的内科医生使用先前测试过的结构化隐式回顾工具，对7个退伍军人事务部医疗中心的111例住院死亡进行了383次回顾，对先前发现与可预防死亡率高相关的标记物进行了过采样。仅接受舒适护理的晚期患者被排除在外。主要结果评价评价最佳护理是否可以预防死亡（按5分制评分）以及如果护理最佳，患者存活至出院或3个月或更长时间的概率结果与以前的研究相似，近四分之一（22.7%）的积极护理患者死亡被评为至少可能通过最佳护理预防，6.0%被评为可能或肯定可预防。这些评级的评分者间可靠性也与以前的研究相似（2名评审员为0.34）。评价者估计，如果提供了最佳护理，存活出院的患者比例为6.0%（95%置信区间[CI]，3.4%-8.6%）。然而，在考虑了3个月的预后并调整了评价者评分的变异性和偏度后，临床医生估计只有0（95%CI，0.3%-0.7%）如果护理是最佳的，死亡的患者将在良好的认知健康中生活3个月或更长时间，代表每10000名住院患者中大约有1名患者进入研究医院。结论医疗差错是一个主要问题，无论患者的预期寿命如何，但我们的研究表明，以前对医疗差错统计的解释可能是误导性的。我们的数据将可预防死亡的估计放在背景中，指出这种识别医疗错误并评估其对患者结局的潜在影响的方法的局限性。
Context Studies using physician implicit review have suggested that the number of deaths due to medical errors in US hospitals is extremely high. However, some have questioned the validity of these estimates.Objective To examine the reliability of reviewer ratings of medical error and the implications of a death described as "preventable by better care" in terms of the probability of immediate and short-term survival if care had been optimal.Design Retrospective implicit review of medical records from 1995-1996.Setting and Participants Fourteen board-certified, trained internists used a previously tested structured implicit review instrument to conduct 383 reviews of 111 hospital deaths at 7 Department of Veterans Affairs medical centers, oversampling for markers previously found to be associated with high rates of preventable deaths. Patients considered terminally ill who received comfort care only were excluded.Main Outcome Measures Reviewer estimates of whether deaths could have been prevented by optimal care (rated on a 5-point scale) and of the probability that patients would have lived to discharge or for 3 months or more if care had been optimal (rated from 0%-100%).Results Similar to previous studies, almost a quarter (22.7 %) of active-care patient deaths were rated as at least possibly preventable by optimal care, with 6.0% rated as probably or definitely preventable. Interrater reliability for these ratings was also similar to previous studies (0.34 for 2 reviewers). The reviewers' estimates of the percentage of patients who would have left the hospital alive had optimal care been provided was 6.0% (95% confidence interval [CI], 3.4%-8.6%). However, after considering 3-month prognosis and adjusting for the variability and skewness of reviewers' ratings, clinicians estimated that only 0.5% (95 % CI, 0.3 % -0.7%) of patients who died would have lived 3 months or more in good cognitive health if care had been optimal, representing roughly 1 patient per 10000 admissions to the study hospitals.Conclusions Medical errors are a major concern regardless of patients' life expectancies, but our study suggests that previous interpretations of medical error statistics are probably misleading. Our data place the estimates of preventable deaths in context, pointing out the limitations of this means of identifying medical errors and assessing their potential implications for patient outcomes.