Inconsistent reporting of minimally invasive surgery errors.
Inconsistent reporting of minimally invasive surgery errors.
复制标题
微创手术错误的报告不一致。
DOI：
10.1308/rcsann.2015.0038
复制
发表时间：
2015
影响因子：
1.4
通讯作者：
R. Wilkie
中科院分区：
文献类型：
--
作者：
A. White;M. Skelton;F. Mushtaq;T. Pike;M. Mon;J. Lodge;R. Wilkie
引言
微创手术是一项复杂的任务，需要灵巧和高水平的认知功能。与外科“从不事件”不同，潜在的重要(和频繁的)手册或认知失误(“技术错误”)研究不足。关于管理信息系统中常规错误的发生，它们与患者预后的关系，以及它们是否得到准确和/或一致的报告，人们知之甚少。
方法
向大不列颠和爱尔兰外科医生协会的所有成员发送了一份电子调查问卷，收集人口统计信息、管理信息系统错误的经验和报告，以及影响错误流行率的因素评级。
结果
在249份回复中，203份回答了超过80%的关于他们在过去12个月中进行的手术的问题。在这些人中，47%的人报告自己的表现中存在重大错误，75%的人知道同事经历了错误。技术技能、知识、情景意识和决策都被认为对避免管理信息系统中的错误特别重要。错误的报告是可变的：15%不一定向患者报告术中错误，而50%不一致地在机构水平报告。关键的是，12%的外科医生不知道报告技术错误的程序，59%的医生认为需要指导。总体而言，40%的人认为保密的报告系统会增加他们报告错误的可能性。
结论
这些数据表明对操作错误的报告不一致，并突出了需要更好地了解管理信息系统中技术错误是如何以及为什么发生的。一个保密的“没有责任”的报告系统可能有助于改善患者的预后，并避免可能破坏公众信心的封闭文化。
INTRODUCTION
Minimally invasive surgery (MIS) is a complex task requiring dexterity and high level cognitive function. Unlike surgical 'never events', potentially important (and frequent) manual or cognitive slips ('technical errors') are underresearched. Little is known about the occurrence of routine errors in MIS, their relationship to patient outcome, and whether they are reported accurately and/or consistently.
METHODS
An electronic survey was sent to all members of the Association of Surgeons of Great Britain and Ireland, gathering demographic information, experience and reporting of MIS errors, and a rating of factors affecting error prevalence.
RESULTS
Of 249 responses, 203 completed more than 80% of the questions regarding the surgery they had performed in the preceding 12 months. Of these, 47% reported a significant error in their own performance and 75% were aware of a colleague experiencing error. Technical skill, knowledge, situational awareness and decision making were all identified as particularly important for avoiding errors in MIS. Reporting of errors was variable: 15% did not necessarily report an intraoperative error to a patient while 50% did not consistently report at an institutional level. Critically, 12% of surgeons were unaware of the procedure for reporting a technical error and 59% felt guidance is needed. Overall, 40% believed a confidential reporting system would increase their likelihood of reporting an error.
CONCLUSION
These data indicate inconsistent reporting of operative errors, and highlight the need to better understand how and why technical errors occur in MIS. A confidential 'no blame' reporting system might help improve patient outcomes and avoid a closed culture that can undermine public confidence.