Confidential reporting of patient safety events in primary care: results from a multilevel classification of cognitive and system factors
Confidential reporting of patient safety events in primary care: results from a multilevel classification of cognitive and system factors
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DOI：
10.1136/qshc.2006.020909
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发表时间：
2007-04-01
影响因子：
--
通讯作者：
Delaney, Brendan
中科院分区：
文献类型：
--
作者：
Kostopoulou, Olga;Delaney, Brendan
目的：使用认知和系统因素的多级分类法对初级保健患者的实际或潜在伤害事件进行分类。方法：对通过保密但非匿名报告系统获得的患者安全事件进行观察性研究。必要时对报告进行后续采访。使用因果树分析事件的原因和影响因素，并使用分类法进行分类。西米德兰兹郡选择了五个综合医疗机构来代表不同规模和类型的患者群体。所有诊所工作人员都被邀请报告患者安全事件。主要结果指标是所报告事件的临床类型的频率、认知错误类型、检测类型和影响因素；以及错误类型、诊所规模、患者后果和检测之间的关系。结果：78 份报告与患者安全相关且可分析。其中包括 21 起 (27%) 不良事件和 50 起 (64%) 未遂事件。 16.7% (13/71) 造成严重的患者后果，包括一名患者死亡。 75.7% (59/78) 有可能对患者造成严重伤害。大多数报告提到了管理错误（25.6%，20/ 78）。 60% (47/78) 的报告包含足够的信息来描述认知特征：45% (21/47) 的报告涉及“情境评估和响应选择”，并且通常与严重的潜在后果相关。最常见的影响因素是工作组织，在 71 个事件中发现。这包括过多的任务要求 (47%, 37/71) 和碎片化 (28%, 22/71)。结论：尽管大多数 报告的事件有惊无险，也报告了对患者造成严重后果的事件。情况评估和反应选择失败是一种在临床和管理任务中发生的认知活动，与严重的潜在危害有关。
Objective: To classify events of actual or potential harm to primary care patients using a multilevel taxonomy of cognitive and system factors.Methods: Observational study of patient safety events obtained via a confidential but not anonymous reporting system. Reports were followed up with interviews where necessary. Events were analysed for their causes and contributing factors using causal trees and were classified using the taxonomy. Five general medical practices in the West Midlands were selected to represent a range of sizes and types of patient population. All practice staff were invited to report patient safety events. Main outcome measures were frequencies of clinical types of events reported, cognitive types of error, types of detection and contributing factors; and relationship between types of error, practice size, patient consequences and detection.Results: 78 reports were relevant to patient safety and analysable. They included 21 (27%) adverse events and 50 (64%) near misses. 16.7% (13/71) had serious patient consequences, including one death. 75.7% (59/78) had the potential for serious patient harm. Most reports referred to administrative errors (25.6%, 20/ 78). 60% (47/78) of the reports contained sufficient information to characterise cognition: "situation assessment and response selection'' was involved in 45% (21/47) of these reports and was often linked to serious potential consequences. The most frequent contributing factor was work organisation, identified in 71 events. This included excessive task demands (47%, 37/71) and fragmentation (28%, 22/71).Conclusions: Even though most reported events were near misses, events with serious patient consequences were also reported. Failures in situation assessment and response selection, a cognitive activity that occurs in both clinical and administrative tasks, was related to serious potential harm.