Analysis of errors reported by surgeons at three teaching hospitals
Analysis of errors reported by surgeons at three teaching hospitals
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DOI：
10.1067/msy.2003.169
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发表时间：
2003-06-01
期刊：
影响因子：
3.8
通讯作者：
Brennan, TA
中科院分区：
文献类型：
--
作者：
Gawande, AA;Zinner, MJ;Brennan, TA
背景对手术失误的潜在因素知之甚少。事件报告已被提议作为获取有关医疗错误信息的方法，以帮助识别此类因素。方法。在2000年11月1日至2001年3月15日期间，我们对来自马萨诸塞州三所教学医院的随机选择的外科医生进行了保密访谈，以获得关于管理错误导致的手术不良事件（“事件”）的详细报告。关于事件特点的数据。记录并分析外科医生报告的导致错误的因素。在45名接受采访的外科医生中，38名（84%）同意参与并提供了146起事件的报告。33%的事件导致永久性残疾，13%的患者死亡。77%涉及与手术或其他侵入性干预相关的损伤（内脏损伤、出血和伤口感染/裂开是最常见的亚型），13%涉及不必要或不适当的手术，10%涉及不必要的疾病进展。三分之二的事件涉及手术护理术中阶段的错误，27%涉及术前管理，22%涉及术后管理。两个或两个以上的临床医生被认为是实质性的，在70%的事件中造成了错误。导致错误的最常见系统因素是缺乏经验/缺乏手术任务能力（53%的事件），人员之间的沟通障碍（43%）以及疲劳或过度工作量（33%）。外科医生报告的急诊手术护理事件中的系统故障明显多于非急诊护理事件（P <0.001）。通过访谈收集的主观事件报告可以识别手术错误的特征及其主要影响因素，这可能有助于有针对性的研究和干预措施，以减少此类错误。
Background. Little is known of the factors that underlie surgical errors. Incident reporting has been proposed as a method of obtaining information about medical errors to help identify such factors.Methods. Between November 1, 2000, and March 15, 2001, we conducted confidential interviews with randomly selected surgeons from three Massachusetts teaching, hospitals to elicit detailed reports on surgical adverse events resulting from errors in management ("incidents"). Data on the characteristics of the incidents and. the factors that surgeons reported to have contributed to the errors were recorded and analyzed.Results. Among 45 surgeons approached for interviews, 38 (84%) agreed to participate and provided reports on 146 incidents. Thirty-three percent of incidents resulted in permanent disability and 13% in patient death. Seventy-seven percent involved injuries related to an operation or other invasive intervention (visceral injuries, bleeding, and wound infection/dehiscence were the most common subtypes), 13% involved unnecessary or inappropriate procedures, and 10% involved unnecessary advancement of disease. Two thirds of the incidents involved errors during the intraoperative phase of surgical care, 27% during preoperative management, and 22% during postoperative management.. Two or more clinicians were cited as substantially, contributing to errors in 70% of the incidents. The most commonly cited systems factors contributing to errors were inexperience/lack of competence in a surgical task (53% of incidents), communication breakdowns among personnel (43%), and fatigue or excessive workload (33%). Surgeons reported significantly more systems failures in incidents involving emergency surgical care than those involving nonemergency care (P < .001).Conclusions. Subjective incident reports gathered through interviews allow identification of characteristics of surgical errors and their leading contributing factors, which may help target research and interventions to reduce such errors.