Fifteen years after To Err is Human: a success story to learn from.
Fifteen years after To Err is Human: a success story to learn from.
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十五年后，err是人类：一个成功的故事。
DOI：
10.1136/bmjqs-2015-004720
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发表时间：
2016-06
影响因子：
5.4
通讯作者：
Srinivasan A
中科院分区：
文献类型：
--
作者：
Pronovost PJ;Cleeman JI;Wright D;Srinivasan A
可预防的伤害是全世界可预防死亡的一个主要原因。1999年底，美国医学研究所（IOM）发布了一份报告，指出美国每年有4.4万到9.8万名患者死于医疗事故，这引起了全世界的关注。事实证明，在减少这些危害方面取得进展是困难的，因为卫生保健缺乏强有力的机制来常规衡量这一问题，而且对其严重程度的估计差异很大。当医疗保健对相同的危害使用多种不同的措施，并且在测量、实施和应用科学方面的投资有限时，很难衡量安全性。中心线相关血流感染（CLABSI）提供了一个值得注意的例外和案例研究的学习。在过去15年中，通过许多人的联合和协调努力，这些感染在重症监护病房（ICU）减少了80%以上，降低了患者死亡率。在本文中，我们反思了预防这些感染的历程，并探讨了这一成功如何为减少其他类型的可预防伤害提供信息和加速努力。虽然这篇论文是对过去工作的综合，但其新颖之处在于提供了CLABSI的历史概况，比较了IOM报告之前和15年后的感染率，并为导致感染大幅减少的原因提供了新的见解。这一过程始于20世纪70年代，当时美国疾病控制与预防中心（CDC）开始收集ICU clabsi的数据。在接下来的几十年里，CDC公布了CLABSI的国家基准数据，调查了血液感染暴发，并于1991年发布了第一份预防血管内导管相关感染的指南。在整个20世纪90年代，这些早期的努力并没有给ICU的CLABSI率带来什么变化，临床医生和政策制定者认为感染是不可避免的。在过去十年中，美国ICU的CLABSI发生率有所下降（表1），如今这些感染在很大程度上是可以预防的。在可预防感染的例子和在大幅减少clabsi的一线护理经验的推动下，态度的转变有助于血液感染率的下降。虽然许多团体和努力对这一减少作出了贡献，而且很难分析这些因素和其他因素的独立贡献，但我们认为，在降低CLABSI比率方面，国家成功的关键是五个因素。我们通过讨论和反思我们的集体经验、理论和出版的文学作品，得出了这五个要素
Preventable harm is a major cause of preventable death worldwide. In late 1999, the Institute of Medicine (IOM) released To Err is Human, 1 a report that riveted the world’s attention to between 44 000 and 98000 patient deaths annually in the USA from medical errors. Progress towards reducing these harms has proven difficult because healthcare lacks robust mechanisms to routinely measure the problem and estimates of the magnitude vary widely. It is hard to gauge safety when healthcare uses multiple different measures for the same harm and provides limited investment in measurement, implementation and applied sciences. Central line-associated bloodstream infection (CLABSI) provides a notable exception and case study for learning. Over the past 15 years, through the combined and coordinated efforts of many, these infections have been reduced over 80% in intensive care units (ICU), decreasing patient mortality. 2 In this essay, we reflect on the journey in preventing these infections and explore how this success can inform and accelerate efforts to reduce other types of preventable harm. While this paper is a synthesis of past work, what is novel is providing the historical profile of CLABSI, comparing infection rates before and 15 years after the IOM report and offering new insights into what led to the substantial reductions in infections. The journey began in the 1970s when the Centers for Disease Control and Prevention (CDC) began collecting data on ICU CLABSIs. Over the next several decades, the CDC published data on national benchmarks for CLABSI, investigated bloodstream infection outbreaks and published the first Guideline for the Prevention of Intravascular Catheter-Related Infections in 1991. These early efforts brought little change in ICU CLABSI rates throughout the 1990s, with clinicians and policy makers believing infections were inevitable.Over the last decade, ICU CLABSI rates have dropped throughout the USA (table 1) and today these infections are considered largely preventable. The attitude change, spurred by examples of preventable infections and experiences at the frontlines of care in substantially reducing CLABSIs, contributed to the drop in bloodstream infection rates. Although many groups and efforts contributed to this reduction and it is difficult to dissect the independent contribution of these and other factors, we believe five elements were essential to the national success in reducing CLABSI rates. We arrived at these five elements through discussion and reflection on our collective experience, theory and the published lit-
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影响因子：
120.7
作者：
Fan, Eddy;Laupacis, Andreas;Needham, Dale M.
通讯作者：
Needham, Dale M.
DOI：
10.1016/s1553-7250(15)41050-5
发表时间：
2015-09-01
影响因子：
2.3
作者：
Gould, Lois J.;Wachter, Patricia A.;Pronovost, Peter J.
通讯作者：
Pronovost, Peter J.
影响因子：
3.7
作者：
Pronovost, Peter J.;Berenholtz, Sean M.;Sexton, J. Bryan
通讯作者：
Sexton, J. Bryan
影响因子：
105.7
作者：
Benning, Amirta;Ghaleb, Maisoon;Lilford, Richard
通讯作者：
Lilford, Richard
影响因子：
4.5
作者：
Wise, Matthew E.;Scott, R. Douglas;Jernigan, John A.
通讯作者：
Jernigan, John A.