Unexpected Clinical Events: Impact on Patient Safety

描述：此修订项目的目标是展示 研究非常规事件（NRE）在实际的病人护理领域， 麻醉学 NRE定义为护理人员感知到的任何事件 提供者或熟练的观察员是不寻常的，不寻常的，或 非典型 因此，NRE表示扰动和平滑专家过程， 可以提供对潜在系统故障的洞察，允许研究过程， 以及护理的结果。 使用麻醉作为结构化医疗的模型 工作环境，调查人员将收集前瞻性和回顾性 关于围手术期非常规事件的数据， 这些事件的分类，并将其与临床结果相关联。 这 研究将确定是否对这些因素进行严格的描述 有助于NRE的发生和恢复 了解安全与不安全医疗实践的区别。 临床经验被假设为影响 NRE的性质和结果。 临床工作量、态势感知、生产 压力和人为错误被假设为NRE的独立预测因子 事件和结果。 直接观察和录像NRE期间 实际的病人护理将提供行为任务分析和测量， 工作量和情况意识。 NRE还将通过系统识别 通过保密报告系统询问恢复室的临床医生， 通过图表筛选。 结构化面试将检查供应商 知识和决策过程方面的NRE思想，管理和 影响结果的因素。 包含NRE的录像带将由 供应商和专家。 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a 先验假设，并描绘NRE频率，类型和 结果。 在第3年，研究人员将开始应用这些方法 麻醉后NRE的识别和分类， 重症监护病房，以描述这种方法将如何推广到非 手术室设置。 拟议的研究，同时产生的应用知识， 减少医疗差错和改善临床护理的具体方法， 更基本的人类认知问题和专业知识的本质。

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.