Mitigation of patient harm from testing errors in family medicine offices: a report from the American Academy of Family Physicians National Research Network.
Mitigation of patient harm from testing errors in family medicine offices: a report from the American Academy of Family Physicians National Research Network.
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减轻家庭医学办公室检测错误对患者造成的伤害：美国家庭医师学会国家研究网络的一份报告。
DOI：
10.1136/qshc.2007.022566
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发表时间：
2008
影响因子：
--
通讯作者：
Hickner,J
中科院分区：
文献类型：
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作者：
Graham,DG;Harris,DM;Elder,NC;Emsermann,CB;Brandt,E;Staton,EW;Hickner,J
很少有研究集中在预防初级保健中发生的错误造成的伤害。我们研究了缓解患者的伤害，通过分析错误报告从家庭医生的office.MethodsThe数据分析来自报告的测试过程中确定的错误家庭医生和他们的办公室工作人员在美国家庭医生学会国家研究网络的8个做法。我们确定如何经常报告的错误事件被缓解，缓解相关的因素和评估缓解的效果错误events.ResultsWe确定缓解的结果在123（21%）的597个测试过程中的事件报告。在确定的缓解者中，79%是来自诊所内部的人，7%是患者或患者家属。年龄较大是与缓解发生可能性增加相关的唯一患者人口统计学属性（未调整OR 18-44岁与65岁或以上= 0.27; p = 0.007）。 包含测试实施错误的事件（11%的事件）缓解的几率较低（未校正OR = 0.40; p = 0.001），包含报告错误的事件（26%的事件）缓解的几率较高（未校正OR = 1.63; p = 0.021）。 随着事件中报告的错误数量增加，该事件被缓解的几率降低（未调整OR = 0.58; p = 0.001）。 多变量逻辑回归显示，如果事件包括订购错误或患者年龄在65岁或以上，则事件缓解的几率较高，如果患者年龄在18岁至44岁之间，或者如果事件包括实施错误或涉及一个以上错误，则缓解的几率较低。缓解事件的患者伤害几率较低（未校正OR = 0.16; p<0.0001），负面后果（未校正OR = 0.28; p<0.0001）。 缓解事件导致不太严重，更少的有害结果相比，非缓解events.ConclusionNearly四分之一的家庭医生及其工作人员报告的测试过程中的错误有证据缓解，减轻错误导致不太频繁，不太严重的伤害病人。在整个测试过程中保持警惕可能会发现和纠正错误，从而防止或减少伤害。
ObjectivesLittle research has focused on preventing harm from errors that occur in primary care. We studied mitigation of patient harm by analysing error reports from family physicians’ offices.MethodsThe data for this analysis come from reports of testing process errors identified by family physicians and their office staff in eight practices in the American Academy of Family Physicians National Research Network. We determined how often reported error events were mitigated, described factors related to mitigation and assessed the effect of mitigation on the outcome of error events.ResultsWe identified mitigation in 123 (21%) of 597 testing process event reports. Of the identified mitigators, 79% were persons from inside the practice, and 7% were patients or patient’s family. Older age was the only patient demographic attribute associated with increased likelihood of mitigation occurring (unadjusted OR 18–44 years compared with 65 years of age or older = 0.27; p = 0.007). Events that included testing implementation errors (11% of the events) had lower odds of mitigation (unadjusted OR = 0.40; p = 0.001), and events containing reporting errors (26% of the events) had higher odds of mitigation (unadjusted OR = 1.63; p = 0.021). As the number of errors reported in an event increased, the odds of that event being mitigated decreased (unadjusted OR = 0.58; p = 0.001). Multivariate logistic regression showed that an event hadhigherodds of being mitigated if it included an ordering error or if the patient was 65 years of age or older, andlowerodds of being mitigated if the patient was between age 18 and 44, or if the event included an implementation error or involved more than one error. Mitigated events had lower odds of patient harm (unadjusted OR = 0.16; p<0.0001) and negative consequences (unadjusted OR = 0.28; p<0.0001). Mitigated events resulted in less severe and fewer detrimental outcomes compared with non-mitigated events.ConclusionNearly a quarter of testing process errors reported by family physicians and their staff had evidence of mitigation, and mitigated errors resulted in less frequent and less serious harm to patients. Vigilance throughout the testing process is likely to detect and correct errors, thereby preventing or reducing harm.