Contributing Factors for Pediatric Ambulatory Diagnostic Process Errors: Project RedDE.
Contributing Factors for Pediatric Ambulatory Diagnostic Process Errors: Project RedDE.
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儿科门诊诊断过程错误的影响因素：RedDE 项目。
DOI：
10.1097/pq9.0000000000000299
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发表时间：
2020
影响因子：
1.1
通讯作者：
Rinke,MichaelL
中科院分区：
文献类型：
--
作者：
Dadlez,NinaM;Adelman,Jason;Bundy,DavidG;Singh,Hardeep;Applebaum,JoR;Rinke,MichaelL
背景：儿科动态诊断错误（DE）经常发生。我们使用根本原因分析 (RCA) 来确定其失败点和影响因素。方法：31 家诊所被纳入全国 QI 合作项目，以减少在诊断过程的不同阶段发生的 3 个 DE：漏检青少年抑郁症、漏检血压升高 (BP) 和漏检可操作的实验室值。鼓励实践每月执行“迷你 RCA”，以确定故障点并优先考虑干预措施。每月报告与所涉及的流程步骤、具体影响因素和建议干预措施相关的信息。使用描述性统计和帕累托图对数据进行分析。结果：二十八家 (90%) 诊所提交了 184 份迷你 RCA。提交的迷你 RCA 的中位数为 6 个（四分位数范围，2-9）。对于漏诊的青少年抑郁症，最常见的处理步骤是未进行筛查（68%）。对于漏诊的血压升高，是因为未能识别（36%）异常血压并采取行动（28%）。对于错过可采取行动的实验室，最常见的流程步骤是未能通知家属（23%）和记录对异常结果采取的行动（19%）。漏诊青少年抑郁症的主要原因包括患者数量（16%）和人员配备不足（13%）。漏诊血压升高的主要原因包括患者数量 (12%)、诊所环境 (9%) 和电子健康记录 (EHR) (8%)。错过可采取行动的实验室的首要因素包括书面沟通 (13%)、EHR (9%) 和提供者知识 (8%)。推荐的干预措施在不同错误中是相似的。结论：基于 EHR 的干预措施、流程标准化和交叉培训可能有助于减少儿科门诊环境中的 DE。迷你 RCA 是确定其影响因素和干预措施的有用工具。
Background:Pediatric ambulatory diagnostic errors (DEs) occur frequently. We used root cause analyses (RCAs) to identify their failure points and contributing factors.Methods:Thirty-one practices were enrolled in a national QI collaborative to reduce 3 DEs occurring at different stages of the diagnostic process: missed adolescent depression, missed elevated blood pressure (BP), and missed actionable laboratory values. Practices were encouraged to perform monthly “mini-RCAs” to identify failure points and prioritize interventions. Information related to process steps involved, specific contributing factors, and recommended interventions were reported monthly. Data were analyzed using descriptive statistics and Pareto charts.Results:Twenty-eight (90%) practices submitted 184 mini-RCAs. The median number of mini-RCAs submitted was 6 (interquartile range, 2–9). For missed adolescent depression, the process step most commonly identified was the failure to screen (68%). For missed elevated BP, it was the failure to recognize (36%) and act on (28%) abnormal BP. For missed actionable laboratories, failure to notify families (23%) and document actions on (19%) abnormal results were the process steps most commonly identified. Top contributing factors to missed adolescent depression included patient volume (16%) and inadequate staffing (13%). Top contributing factors to missed elevated BP included patient volume (12%), clinic milieu (9%), and electronic health records (EHRs)(8%). Top contributing factors to missed actionable laboratories included written communication (13%), EHR (9%), and provider knowledge (8%). Recommended interventions were similar across errors.Conclusions:EHR-based interventions, standardization of processes, and cross-training may help decrease DEs in the pediatric ambulatory setting. Mini-RCAs are useful tools to identify their contributing factors and interventions.