Defining near misses: Towards a sharpened definition based on empirical data about error handling processes
Defining near misses: Towards a sharpened definition based on empirical data about error handling processes
复制标题
DOI：
10.1016/j.socscimed.2010.01.006
复制
发表时间：
2010-05-01
影响因子：
5.4
通讯作者：
Rutte, Christel
中科院分区：
文献类型：
--
作者：
Kessels-Habraken, Marieke;Van der Schaaf, Tjerk;Rutte, Christel
医疗保健中的医疗差错仍然经常发生。不幸的是，错误无法完全避免，也永远无法实现100%的安全性。因此，除了减少错误的策略，医疗机构还可以实施促进及时发现和纠正错误的策略。报告和分析所谓的未遂事件-通常定义为没有对患者造成不良后果的事件-对于收集有关成功错误恢复机制的信息是必要的。这项研究确定，有必要对未遂事件作出更明确和更一致的定义，以便能够进行大规模的报告和分析，从而获得此类信息。定性事件报告和访谈收集了两个荷兰综合医院的四个单位。对143个伴随的错误处理过程的分析表明，不同的事件类型都提供了关于错误处理的独特信息。具体而言，由于在错误检测后采取了成功的对策，因此未到达患者的事件的错误处理过程与到达患者的事件的错误处理过程存在显著差异，无论是否造成伤害。我们提出了两种可能的定义，近的失误，并认为，从实际的角度来看，最佳的定义可能是视组织环境。这两个拟议的定义都可能导致大规模的未遂事件报告。随后的分析可以使医疗保健组织通过以下方式主动改善护理的安全性和质量：（1）在真实的事故发生之前消除故障因素，（2）提高他们及时拦截错误的能力，以及（3）改善他们的安全文化。(C)2010爱思唯尔有限公司版权所有。
Medical errors in health care still occur frequently. Unfortunately, errors cannot be completely prevented and 100% safety can never be achieved. Therefore, in addition to error reduction strategies, health care organisations could also implement strategies that promote timely error detection and correction. Reporting and analysis of so-called near misses - usually defined as incidents without adverse consequences for patients - are necessary to gather information about successful error recovery mechanisms. This study establishes the need for a clearer and more consistent definition of near misses to enable large-scale reporting and analysis in order to obtain such information. Qualitative incident reports and interviews were collected on four units of two Dutch general hospitals. Analysis of the 143 accompanying error handling processes demonstrated that different incident types each provide unique information about error handling. Specifically, error handling processes underlying incidents that did not reach the patient differed significantly from those of incidents that reached the patient, irrespective of harm, because of successful countermeasures that had been taken after error detection. We put forward two possible definitions of near misses and argue that, from a practical point of view, the optimal definition may be contingent on organisational context. Both proposed definitions could yield large-scale reporting of near misses. Subsequent analysis could enable health care organisations to improve the safety and quality of care proactively by (1) eliminating failure factors before real accidents occur, (2) enhancing their ability to intercept errors in time, and (3) improving their safety culture. (C) 2010 Elsevier Ltd. All rights reserved.