Contextual Errors in Medical Decision Making: Overlooked and Understudied
Contextual Errors in Medical Decision Making: Overlooked and Understudied
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DOI：
10.1097/acm.0000000000001017
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发表时间：
2016-05-01
影响因子：
7.4
通讯作者：
Schwartz, Alan
中科院分区：
文献类型：
--
作者：
Weiner, Saul J.;Schwartz, Alan
尽管人们普遍认为有效的临床实践需要关注个体患者的情况和需求-他们的生活背景-而不仅仅是治疗疾病，但很少评估不这样做的影响。例如，如果处方的药物适用于治疗某种临床疾病，但不适用于某个特定的个体，因为他或她负担不起，缺乏正确使用药物的技能，或者由于责任冲突（如上夜班）而无法坚持治疗方案，那么会有什么后果？反过来说，在处理这些背景因素时，健康和保健有什么好处？最后，可以采用和开发的临床医生的行为与情境化护理，以指导护理的改进？作者通过观察性和实验性研究探讨了这些问题，以定义患者背景的参数，引入测量临床医生对患者背景的关注的策略，并评估这种关注对护理计划，患者医疗保健结果和成本的影响。作者认为，不注意病人的情况是一个未被认识到的医疗错误（“上下文错误”）的原因，检测其存在通常需要在访问中倾听，它对护理质量有重大影响。还描述了减少上下文错误的初步工作。有证据表明，这一新兴领域的研究有显着的影响，绩效评估和医学教育，在解决赤字的护理质量。
Although it is widely recognized that effective clinical practice requires attending to the circumstances and needs of individual patients-their life context-rather than just treating disease, the implications of not doing so are rarely assessed. What are, for instance, the consequences of prescribing a medication that is appropriate for treating a clinical condition but inappropriate for a particular individual either because she or he cannot afford it, lacks the skills to administer it correctly, or is unable to adhere to the regimen because of competing responsibilities such as working the night shift? Conversely, what are the gains to health and health care when such contextual factors are addressed? Finally, can performance measures be employed and developed for the clinician behaviors associated with contextualizing care to guide improvements in care? The authors have explored these questions through observational and experimental studies to define the parameters of patient context, introduce strategies for measuring clinician attention to patient context, and assess the impact of that attention on care planning, patient health care outcomes, and costs. The authors suggest that inattention to patient context is an underrecognized cause of medical error ("contextual error"), that detecting its presence usually requires listening in on the visit, and that it has significant implications for quality of care. Also described is preliminary work to reduce contextual errors. Evidence suggests that this nascent area of research has significant implications for performance assessment and medical education in addressing deficits in quality of care.