Detection of medical errors in kidney transplantation: a pilot study comparing proactive clinician debriefings to a hospital-wide incident reporting system.
Detection of medical errors in kidney transplantation: a pilot study comparing proactive clinician debriefings to a hospital-wide incident reporting system.
复制标题
肾移植中医疗错误的检测：一项试点研究，将主动临床医生汇报与全院事件报告系统进行比较。
DOI：
10.1016/j.surg.2014.05.013
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发表时间：
2014
期刊：
影响因子：
3.8
通讯作者：
Ladner,DanielaP
中科院分区：
文献类型：
--
作者：
McElroy,LisaM;Daud,Amna;Lapin,Brittany;Ross,Olivia;Woods,DonnaM;Skaro,AntonI;Holl,JaneL;Ladner,DanielaP
背景 对于接受肾移植的患者来说，医疗错误和不良事件的发生率仍然很高；由于其疾病和肾移植程序的复杂性，他们特别容易受到伤害。尽管全国各地的医院都使用机构事件报告系统，但它们往往无法捕获相当大比例的医疗错误。本研究的目的是评估主动的、基于网络的临床医生安全汇报的能力，以增强通过传统事件报告系统获得的有关医疗错误和不良事件的信息。方法将汇报发送给 2010 年 4 月至 2011 年 4 月期间肾移植手术手术室人员报告中列出的所有个人，并收集同一时期的事故报告。世界卫生组织国际患者安全分类用于对所有报告的问题进行分类。结果总共 270 份报告报告了 334 起患者安全问题（179 起安全事件，155 个影响因素），57 份事件报告报告了 92 起患者安全问题（56 起安全事件，36 个影响因素）。与事件报告相比，更多的主治医生完成了情况汇报（32.0% vs 3.5%）。 讨论 在评估肾移植的安全风险时，使用主动的、基于网络的情况汇报来增强事件报告系统，显示出更多的信息、对单一安全问题的更多观点以及参与者的广度。
BackgroundRates of medical errors and adverse events remain high for patients who undergo kidney transplantation; they are particularly vulnerable because of the complexity of their disease and the kidney transplantation procedure. Although institutional incident-reporting systems are used in hospitals around the country, they often fail to capture a substantial proportion of medical errors. The goal of this study was to assess the ability of a proactive, web-based clinician safety debriefing to augment the information about medical errors and adverse events obtained via traditional incident reporting systems.MethodsDebriefings were sent to all individuals listed on operating room personnel reports for kidney transplantation surgeries between April 2010 and April 2011, and incident reports were collected for the same time period. The World Health Organization International Classification for Patient Safety was used to classify all issues reported.ResultsA total of 270 debriefings reported 334 patient safety issues (179 safety incidents, 155 contributing factors), and 57 incident reports reported 92 patient safety issues (56 safety incidents, 36 contributing factors). Compared with incident reports, more attending physicians completed the debriefings (32.0 vs 3.5%).DiscussionThe use of a proactive, web-based debriefing to augment an incident reporting system in assessing safety risks in kidney transplantation demonstrated increased information, more perspectives of a single safety issue, and increased breadth of participants.