Testing process errors and their harms and consequences reported from family medicine practices: a study of the American Academy of Family Physicians National Research Network
Testing process errors and their harms and consequences reported from family medicine practices: a study of the American Academy of Family Physicians National Research Network
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DOI：
10.1136/qshc.2006.021915
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发表时间：
2008-06-01
影响因子：
--
通讯作者：
Phillips, R.
中科院分区：
文献类型：
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作者：
Hickner, J.;Graham, D. G.;Phillips, R.
背景：对初级保健中发生的检测过程错误的类型和结果知之甚少。目的：描述家庭医生和办公室工作人员报告的检测错误的类型、预测因素和结果。设计：匿名报告事件。每个办公室在事件报道之前完成了一份描述他们测试过程的调查。设置和参与者：8个家庭医学办公室的243名临床医生和办公室工作人员。主要结果测量：错误类型的分布、与潜在预测因素的关联、危害的预测因素和错误的后果。结果：参与者提交了590个事件报告，966个测试过程错误。差错发生在排序检验(12.9%)、实施检验(17.9%)、向临床医生报告结果(24.6%)、临床医生对结果作出反应(6.6%)、通知病人结果(6.8%)、一般管理(17.6%)、沟通(5.7%)和其他类别(7.8%)。图表或归档错误占错误的14.5%。差错类型与报告类型(临床医生或工作人员)、诊所使用的实验室数量、缺乏结果跟踪系统以及患者的种族/民族之间存在显著的相关性(p<；0.05)。不良后果包括时间损失和经济后果(22%)、护理延误(24%)、疼痛/痛苦(11%)和不良临床后果(2%)。在54%的事件中，患者没有受到伤害；18%的患者造成了一些伤害，28%的患者的伤害状态未知。采用多水平Logistic回归分析，不良后果或伤害在临床医生报告的事件中更常见，涉及年龄在45-之间的患者，并涉及测试实施错误。少数族裔患者比非西班牙裔白人患者更容易遭受不良后果或伤害。结论：在整个测试过程中都会发生错误，最常见的是测试实施和向临床医生报告结果。虽然严重的身体伤害是罕见的，但对患者的不良后果是常见的。少数族裔患者的伤害和不良后果发生率较高，这是一个令人担忧的差距，需要进一步调查。
Context: Little is known about the types and outcomes of testing process errors that occur in primary care.Objective: To describe types, predictors and outcomes of testing errors reported by family physicians and office staff.Design: Events were reported anonymously. Each office completed a survey describing their testing processes prior to event reporting.Setting and participants: 243 clinicians and office staff of eight family medicine offices.Main outcome measures: Distribution of error types, associations with potential predictors; predictors of harm and consequences of the errors.Results: Participants submitted 590 event reports with 966 testing process errors. Errors occurred in ordering tests (12.9%), implementing tests (17.9%), reporting results to clinicians (24.6%), clinicians responding to results (6.6%), notifying patient of results (6.8%), general administration (17.6%), communication (5.7%) and other categories (7.8%). Charting or filing errors accounted for 14.5% of errors. Significant associations (p < 0.05) existed between error types and type of reporter ( clinician or staff), number of labs used by the practice, absence of a results follow-up system and patients' race/ethnicity. Adverse consequences included time lost and financial consequences (22%), delays in care (24%), pain/suffering (11%) and adverse clinical consequence (2%). Patients were unharmed in 54% of events; 18% resulted in some harm, and harm status was unknown for 28%. Using multilevel logistic regression analyses, adverse consequences or harm were more common in events that were clinician-reported, involved patients aged 45-64 years and involved test implementation errors. Minority patients were more likely than white, non-Hispanic patients to suffer adverse consequences or harm.Conclusions: Errors occur throughout the testing process, most commonly involving test implementation and reporting results to clinicians. While significant physical harm was rare, adverse consequences for patients were common. The higher prevalence of harm and adverse consequences for minority patients is a troubling disparity needing further investigation.