Patterns of communication breakdowns resulting in injury to surgical patients
Patterns of communication breakdowns resulting in injury to surgical patients
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DOI：
10.1016/j.jamcollsurg.2007.01.010
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发表时间：
2007-04-01
影响因子：
5.2
通讯作者：
Gawande, Atul A.
中科院分区：
文献类型：
--
作者：
Greenberg, Caprice C.;Regenbogen, Scott E.;Gawande, Atul A.
背景：通信故障是一个共同的威胁，手术安全，但有很少的数据来指导倡议，以改善communications.Study设计：在外科医生审查444手术医疗事故索赔4责任保险公司，我们确定了60例涉及通信故障造成伤害的病人。两名外科医生评审员分析了这些病例，以确定共同特征和相关因素。基于所确定的模式，潜在的干预措施，以防止通信故障的开发和其潜在的影响进行了assessed.RESULTS：60例涉及81通信故障，发生在术前（38%），术中（30%），术后期间（32%）。72%的案件涉及一次沟通中断。大部分故障是口头沟通（92%），涉及1个发送者和1个接收者（64%）。主治外科医生是最常见的参与团队成员。地位不对称（74%）和职责模糊（73%）是常见的相关因素。43%的通信故障发生在病人所在地，39%发生在病人所在地的转移。最常见的沟通故障涉及居民未能通知主治外科医生的关键事件和失败的出席出席出席的医生。建议的干预措施可以防止45%至73%的沟通故障，在这种情况下series.CONCLUSIONS：严重的沟通故障发生在整个护理的连续性，通常是由于一个失败的手术主治医生和另一个照顾者之间的口头沟通，并往往涉及模糊的责任。预防这些故障的干预措施应包括：定义触发器，要求与主治外科医生进行沟通;结构化检查和传输协议;以及标准使用回读。（美国科尔外科杂志2007;204：533-540。(C)2007年由美国外科医生学会出版）。
BACKGROUND:Communication breakdowns are a common threat to surgical safety, but there are little data to guide initiatives to improve communication.STUDY DESIGN:In surgeon-review of 444 surgical malpractice claims from 4 liability insurers, we identified 60 cases involving communication breakdowns resulting in harm to patients. Two surgeon-reviewers analyzed these cases to identify common characteristics and associated factors. Based on identified patterns, potential interventions to prevent communication breakdowns were developed and their potential impact was assessed.RESULTS:The 60 cases involved 81 communication breakdowns, occurring in the preoperative (38%), intraoperative (30%), and postoperative periods (32%). Seventy-two percent of cases involved one communication breakdown. The majority of breakdowns were verbal communications (92%) involving 1 transmitter and 1 receiver (64%). Attending surgeons were the most common team member involved. Status asymmetry (74%) and ambiguity about responsibilities (73%) were commonly associated factors. Forty-three percent of communication breakdowns occurred with handoffs and 39% with transfers in the patient's location. The most common Communication breakdowns involved residents failing to notify the attending surgeon of critical events and a failure of attending-to-attending handoffs. Proposed interventions could prevent 45% to 73% of communication breakdowns in this cases series.CONCLUSIONS:Serious communication breakdowns occur across the continuum of care, typically result from a failure in verbal communication between a surgical attending and another caregiver, and often involve ambiguity about responsibilities. Interventions to prevent these breakdowns should involve: defined triggers that mandate communication with an attending surgeon; structured handoffs and transfer protocols; and standard use of read-backs. (J Am Coll Surg 2007;204: 533-540. (C) 2007 by the American College of Surgeons).