Analysis of unintended events in hospitals: inter-rater reliability of constructing causal trees and classifying root causes
Analysis of unintended events in hospitals: inter-rater reliability of constructing causal trees and classifying root causes
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DOI：
10.1093/intqhc/mzp023
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发表时间：
2009-08-01
影响因子：
2.6
通讯作者：
Wagner, Cordula
中科院分区：
文献类型：
--
作者：
Smits, Marleen;Janssen, Jasper;Wagner, Cordula
根本原因分析是一种检查意外事件原因的方法。PRISMA(监测和分析预防和恢复信息系统)是一个根本原因分析工具。在PRISMA中，事件在因果树中描述，并随后使用Eindhoven分类模型(ECM)对根本原因进行分类。重要的是根本原因分析工具是可靠的，因为它们构成了患者安全干预的基础。确定根本原因的描述、数量和分类的评分者之间的可靠性。总共从30个医院单位的2028个事件的数据库中抽取了300个意外事件报告。这些报告之前由经验丰富的分析员使用PRISMA进行分析，并重新分析以比较根本原因的描述和数量(n=150)，并确定分类的评价者间的可靠性(n=150)。百分比一致性和Cohen的kappa(Kappa)。根本原因描述之间的一致性令人满意：54%的一致性，17%的部分一致性和29%的不一致性。评分者之间对根本原因数量的可靠性为中等(kappa=0.46)。从最高分类水平(kappa=0.71)到最低分类水平(kappa=0.63)，使用ECM对根本原因进行分类的评分者之间的可靠性是显著的。结果表明，用PRISMA进行因果树分析是可靠的。分析人员制定了类似的根本原因，并在分类上达成了相当大的一致，但根本原因的数量有所不同。建议开展更多关于披露所有相关根本原因的培训，并通过将所有外部原因合并为一个类别来调整模型。
Root cause analysis is a method to examine causes of unintended events. PRISMA (Prevention and Recovery Information System for Monitoring and Analysis) is a root cause analysis tool. With PRISMA, events are described in causal trees and root causes are subsequently classified with the Eindhoven Classification Model (ECM). It is important that root cause analysis tools are reliable, because they form the basis for patient safety interventions.Determining the inter-rater reliability of descriptions, number and classifications of root causes.Totally, 300 unintended event reports were sampled from a database of 2028 events in 30 hospital units. The reports were previously analysed using PRISMA by experienced analysts and were re-analysed to compare descriptions and number of root causes (n = 150) and to determine the inter-rater reliability of classifications (n = 150).Percentage agreement and Cohen's kappa (kappa).Agreement between descriptions of root causes was satisfactory: 54% agreement, 17% partial agreement and 29% no agreement. Inter-rater reliability of number of root causes was moderate (kappa = 0.46). Inter-rater reliability of classifying root causes with the ECM was substantial from highest category level (kappa = 0.71) to lowest subcategory level (kappa = 0.63). Most discrepancies occurred in classifying external causes.Results indicate that causal tree analysis with PRISMA is reliable. Analysts formulated similar root causes and agreed considerably on classifications, but showed variation in number of root causes. More training on disclosure of all relevant root causes is recommended as well as adjustment of the model by combining all external causes into one category.