Analysing potential harm in Australian general practice: an incident-monitoring study
Analysing potential harm in Australian general practice: an incident-monitoring study
复制标题
DOI：
10.5694/j.1326-5377.1998.tb140186.x
复制
发表时间：
1998-07-20
影响因子：
11.4
通讯作者：
Britt, HC
中科院分区：
文献类型：
--
作者：
Bhasale, AL;Miller, GC;Britt, HC
目的：收集对全科医生造成潜在或实际伤害的事件的数据，并评估这些事件的可能原因。设计：基于改进的关键事件技术对潜在伤害事件进行观察性研究。全科医生 (GP) 的非随机样本同时匿名提交事件报告。背景和参与者：1993 年 10 月至 1995 年 6 月期间的澳大利亚全科医生。在研究期间，有 324 名全科医生在某个时间参与。主要结果指标：全科医生报告的事件的自由文本描述和可预防性的结构化响应、潜在伤害、直接后果、预测的长期结果、事件类型、促成因素、缓解因素、结果：报告了 805 起事件 - 76% 是可以预防的； 27% 有可能造成严重伤害。 66% 的事件预计不会造成长期伤害。事件可能与药物管理（每 100 起事件 51 起）、非药物管理（每 100 起事件 42 起）、诊断（每 100 起事件 34 起）或设备（每 100 起事件 5 起）有关。最常见的促成因素是患者和医疗保健专业人员之间的沟通不畅以及其他人的行为（每 100 起事件中有 23 起）以及判断错误（每 100 起事件中有 22 起）。结论：确定了人为错误和可预防的系统问题。事件监测技术提供了有用的数据，可应用于事件预防策略。
Objective: To collect data on incidents of potential or actual harm to general practice patients and to evaluate the possible causes of these incidents.Design: An observational study of incidents of potential harm based on a modified critical incidents technique. A non-random sample of general practitioners (GPs) anonymously submitted incident reports contemporaneously.Setting and participants: Australian general practices between October 1993 and June 1995. During the study period, 324 GPs participated at some time.Main outcome measures: GP-reported free-text descriptions of incidents and structured responses for preventability, potential for harm, immediate consequences, predicted long-term outcomes, type of incident, contributing factors, mitigating factors, and additional resource use.Results: 805 incidents were reported - 76% were preventable; 27% had potential for severe harm. No long term harm was predicted for 66% of incidents. Incidents could relate to pharmacological management (51 per 100 incidents), nonpharmacological management (42 per 100 incidents), diagnosis (34 per 100 incidents) or equipment (5 per 100 incidents). The most common contributory factors were poor communication between patients and healthcare professionals and actions of others (23 per 100 incidents each) and errors in judgement (22 per 100 incidents).Conclusion: Human errors and preventable system problems were identified. The incident monitoring technique provided useful data which could be applied to incident prevention strategies.