Unexpected Clinical Events: Impact on Patient Safety

描述：本修订项目的目标是展示在实际患者护理过程中研究非常规事件(NRE)的价值 麻醉学。NRE被定义为由CARE感知的任何事件 提供者或熟练的观察者是不寻常的，不寻常的，或者 非典型的。因此，NRE代表扰动和光滑的专家过程和 可提供对潜在系统故障的洞察，从而使过程研究成为 以及护理的结果。将麻醉作为结构化医学的一个模型 工作环境方面，调查员将收集前瞻性和回溯性资料 围手术期非常规事件的数据，发展出有用的 对这类事件进行分类，并将它们与临床结果联系起来。这 研究将确定对这些因素的严格表征 有助于NRE的发生和从NRE中恢复 了解如何区分安全和不安全的医疗实践。 临床经验被认为是影响 NRE的性质和结果。临床工作量、情境感知、生产 假设压力和人为错误是NRE的独立预测因素 事件和结果。NRE期间的直接观测和录像 实际的病人护理将提供行为任务分析和测量 工作量和情境意识。NRE还将由系统化的 通过保密报告系统查询恢复室的临床医生， 并通过图表筛选。结构化面谈将审查供应商 关于NRE思想、管理和决策的知识和决策过程 影响结果的因素。包含NRE的录像带将由 由供应商和专家提供。每个NRE将被分类并记录在 数据库。互补的多变量分析技术将测试一个 先验假设并描绘了NRE频率、类型和 结果。在第三年，调查人员将开始应用这些方法 麻醉后NRE的鉴定和分类 描述这种方法将如何推广到非重症监护病房 或布景。拟议的研究在产生应用知识的同时， 减少医疗差错和改善临床护理的具体方法也涉及 更根本的问题是人类认知和专业知识的性质。

DESCRIPTION: The goal of this revised project is to demonstrate the value of studying non-routine events (NRE) during actual patient care in the field of anesthesiology. An NRE is defined as any event that is perceived by care providers or skilled observers to be unusual, out of the ordinary, or atypical. NRE thus represents perturbations and smooth expert processes and may provide insight into potential system faults, allowing study of process as well as outcome of care. Using anesthesia as a model of a structured medical work environment, the investigators will collect prospective and retrospective data on non-routine events in the perioperative period, develop a useful classification of such events, and relate them to clinical outcomes. This research will ascertain whether rigorous characterization of the factors contributing to the occurrence of, and recovery from, NRE facilitates understanding what distinguishes safe versus unsafe medical practice. Clinical experience is hypothesized to be a principal factor influencing the nature and outcome of NRE. Clinical workload, situation awareness, production pressure and human error are hypothesized to be independent predictors of NRE incidents and outcome. Direct observation and video taping of NRE during actual patient care will provide behavioral task analysis and measurement of workload and situation awareness. NRE will also be identified by systematic query of clinicians in the recovery room, by a confidential reporting system, and by chart screening. Structured interviews will examine providers knowledge and decision processes with regard to NRE ideology, management and factors influencing outcome. NRE-containing video tapes will be reviewed by providers and by experts. Each NRE will be categorized and logged in a database. Complementary multivariate analysis techniques will test the a priori hypotheses and delineate other predictors of NRE frequency, type, and outcome. In year 3 the investigators will begin to apply these methodologies of identification and categorization of NRE in the post-anesthesia and intensive care units to delineate how this approach will generalize to a non- OR setting. The proposed studies, while yielding applied knowledge of specific ways to reduce medical error and improve clinical care, also address more fundamental issues of human cognition and the nature of expertise.