Medical errors and clinical risk management: state of the art.
Medical errors and clinical risk management: state of the art.
复制标题
医疗错误和临床风险管理：最先进的。
DOI：
--
复制
发表时间：
2005
期刊：
影响因子：
--
通讯作者：
Direzione Sanitaria
中科院分区：
文献类型：
--
作者：
L. L. Pietra;L. Calligaris;L. Molendini;R. Quattrin;S. Brusaferro;Direzione Sanitaria
医疗差错是一个严重的公共卫生问题，对患者安全构成威胁。所有患者都有潜在的脆弱性，因此从人类、经济和社会的角度来看，医疗差错都是代价高昂的。本报告的目的不仅是在已发表文献的基础上概述这一问题，而且强调采用标准术语和分类的重要性，这些术语和分类是研究人员获得有效和可靠的错误识别和报告方法的基本工具。事实上，就标准定义达成一致可以比较不同情况下的数据。差错可以根据其结果、发生地点(住院、门诊)、涉及的程序类型(药物、手术等)进行分类。或发生的概率(高、低)。对差错类别进行分析时考虑到了差错的普遍性、避免和相关因素，以及不同的医疗差错检测策略。事故报告和险情记录被描述为有用的信息来源，医疗故障模式影响分析(HFMEA)和根本原因分析(RCA)被视为流程分析的强大方法。此外，提高患者安全性的方法在临床风险管理的更广泛背景下被考虑。医疗差错领域的新方法旨在最大限度地减少与较高错误率相关的可避免模式的复发。旨在改善组织业绩的系统方法和无责备的环境会产生比关注个人好得多的结果。此外，使用技术、信息可获得性、交流、患者协作和多专业团队合作是在医疗保健组织内实现患者安全目标的成功策略。
Medical errors represent a serious public health problem and pose a threat to patient safety. All patients are potentially vulnerable, therefore medical errors are costly from a human, economic, and social viewpoint. The present report aims not only to provide an overview of the problem on the basis of the published literature, but also to stress the importance of adopting standard terminology and classifications, fundamental tools for researchers to obtain valid and reliable methods for error identification and reporting. In fact, agreement on standard definitions allows comparison of data in different contexts. Errors can be classified according to their outcome, the setting where they take place (inpatient, outpatient), the kind of procedure involved (medication, surgery, etc.) or the probability of occurring (high, low). Error categories are analysed taking into consideration their prevalence, avoidance and associated factors as well as the different strategies for detecting medical errors. Incident reporting and documentation of near-misses are described as useful sources of information, and Healthcare Failure Mode Effect Analysis (HFMEA) and Root Cause Analysis (RCA) are seen as powerful methods for process analysis. Furthermore, means to increase patient safety are considered in the broader context of clinical risk management. New approaches in the field of medical errors are aimed at minimizing the recurrence of avoidable patterns associated with higher error rate. A system approach and a blame-free environment, aimed at better organizational performances, lead to much better results than focusing on individuals. Furthermore, use of technology, information accessibility, communication, patient collaboration and multi-professional team-work are successful strategies to reach the goal of patient safety within healthcare organizations.