Contextual Errors and Failures in Individualizing Patient Care A Multicenter Study
Contextual Errors and Failures in Individualizing Patient Care A Multicenter Study
复制标题
DOI：
10.7326/0003-4819-153-2-201007200-00002
复制
发表时间：
2010-07-20
影响因子：
39.2
通讯作者：
Abrams, Richard I.
中科院分区：
文献类型：
--
作者：
Weiner, Saul J.;Schwartz, Alan;Abrams, Richard I.
背景资料：当医生忽略了患者的环境或行为的元素时，就会发生上下文错误，这些元素对计划适当的护理至关重要。与非患者特异性的生物医学错误相反，背景错误代表了个性化护理的失败。目的：探讨医生探测背景和生物医学红旗的频率和情况，并通过整合他们从这些探测器中学到的知识来避免治疗错误。设计：一种不完全随机区组设计，标准化患者在2007年4月至2009年4月期间访问了111名内科主治医生，并提出了4种情景的变体。在所有情况下，患者都表现出背景和生物医学红旗。对旗帜的调查反应各不相同，无论他们是否揭示了一个潜在的复杂的生物医学或背景因素（或两者兼而有之），如果忽视，将导致错误的管理。设置：14个做法，包括2个学术诊所，2个社区为基础的初级保健网络与多个网站，一个核心安全网提供商，和3个U。S. Department of Veterans Affairs facilities.Measurements：Primary outcomes were the proportion of visits in which Physicians probably for contextual and biomedical factors in response to hints or red flag and the proportion of visits that lead in error-free treatment plannes.Results：Physicians probably less contextual red flag（51%）than biomedical red flag（63%）.探测背景或生物医学信息，以响应红旗通常是必要的，但不足以为一个无错误的护理计划。在73%的无并发症的遭遇，38%的生物医学复杂的遭遇，22%的背景复杂的遭遇，和9%的组合生物医学和背景复杂的遭遇。该研究评估了医生在每次就诊时都有机会犯错的倾向，并且没有测量由于不注意上下文而在初级保健环境中发生的实际错误率。不注意上下文信息，如患者的交通需求，经济状况或看护责任，可能导致上下文错误，目前在医生表现的评估中没有测量。
Background: A contextual error occurs when a physician overlooks elements of a patient's environment or behavior that are essential to planning appropriate care. In contrast to biomedical errors, which are not patient-specific, contextual errors represent a failure to individualize care.Objective: To explore the frequency and circumstances under which physicians probe contextual and biomedical red flags and avoid treatment error by incorporating what they learn from these probes.Design: An incomplete randomized block design in which unannounced, standardized patients visited 111 internal medicine attending physicians between April 2007 and April 2009 and presented variants of 4 scenarios. In all scenarios, patients presented both a contextual and a biomedical red flag. Responses to probing about flags varied in whether they revealed an underlying complicating biomedical or contextual factor (or both) that would lead to errors in management if overlooked.Setting: 14 practices, including 2 academic clinics, 2 community-based primary care networks with multiple sites, a core safety net provider, and 3 U. S. Department of Veterans Affairs facilities.Measurements: Primary outcomes were the proportion of visits in which physicians probed for contextual and biomedical factors in response to hints or red flags and the proportion of visits that resulted in error-free treatment plans.Results: Physicians probed fewer contextual red flags (51%) than biomedical red flags (63%). Probing for contextual or biomedical information in response to red flags was usually necessary but not sufficient for an error-free plan of care. Physicians provided error-free care in 73% of the uncomplicated encounters, 38% of the biomedically complicated encounters, 22% of the contextually complicated encounters, and 9% of the combined biomedically and contextually complicated encounters.Limitations: Only 4 case scenarios were used. The study assessed physicians' propensity to make errors when every encounter provided an opportunity to do so and did not measure actual error rates that occur in primary care settings because of inattention to context.Conclusion: Inattention to contextual information, such as a patient's transportation needs, economic situation, or caretaker responsibilities, can lead to contextual error, which is not currently measured in assessments of physician performance.