美国医疗风险监测预警机制现状及绩效的循证评价

目的循证评价美国医疗风险监测预警机制的经验及其对我国医疗风险监管系统建立的借鉴意义。方法检索相关数据库和网络资源,全面收集有关美国医疗风险管理、医疗差错、病人安全和安全教育等方面的文献,将文献质量按循证科学的原理和方法进行分级并分类统计。结果1999年美国医学研究所(IOM)《犯错人皆难免,构建更安全的医疗卫生系统》的报告,揭示了美国医疗差错的严重性,同时指出了问题的根源并提出了解决途径。2000年,政府指定国家质量协调特别工作组(QuIC)评估IOM报告并制订了具体的整改措施。经过5年改革,在增强公众医疗差错意识、建立病人安全中心、制定医疗安全执行标准、应用信息技术、建立差错报告系统等方面取得了一定的成绩,建立了完善的医疗风险监管机制。但在风险防范方面仍存在一定不足。结论我国在建立医疗风险监管体系时应结合自身的特点:①普及和加强公众的医疗风险、病人安全意识,支持和开展病人安全相关研究;②建立医院检查审核制度和医务人员的定期考核管理制度,重视和加强医务人员的继续教育及医学生有关医疗风险知识的在校教育;③应用循证科学的原理和方法,制定涉及医疗保健系统、采购系统、药物供应系统等各个方面相应的制度和指南,规范操作制度和管理;④利用计算机信息技术,促进医院的信息化建设和规范化管理,减少人为因素的影响;⑤在选点示范、逐步推行的同时,应用循证科学的原理和方法后效评价,止于至善。     

Between a rock and a hard place: disclosing medical errors

BACKGROUND: Healthcare-related errors cause patient morbidity and mortality. Despite fear of reprimand, laboratory personnel have a professional obligation to rapidly report major medical errors when they are identified. Well-defined protocols regarding how and when to disclose a suspected error by a colleague do not exist. Patient: We describe a woman with a well documented allergy to sulfamethoxazole who was treated with sulfadiazine that led to toxic epidermal necrolysis. After the patient's death, the laboratory medicine resident was asked by one of the patient's physicians to measure serum sulfadiazine, but only if the results were not reported in the patient's electronic medical record. The case was brought to the attention of a laboratory medicine faculty member and the hospital risk management team. Issues: Laboratorians are patient fiduciaries and are responsible for reporting errors. Most medical associations have codes of ethics that address disclosure of incompetence and errors, although the AACC's Guide to Ethics does not. New types of error, risk management, and root-cause analyses help to shift the focus to system errors and away from individuals' errors. This can lead to a healthcare environment that encourages truth and disclosure rather than fear and reprimand. Disposition: The individuals involved in the presented case fulfilled their fiduciary duty to the patient by reporting this incident. An extensive investigation showed that, in fact, no medical errors or misconducts had occurred in the care of the patient.     

临床路径的应用现状

临床路径是在美国20世纪80年代后期,医疗保险的支付方式发生了变更的背景下产生的。临床路径是旨在提高医疗、护理质量的工具表。与传统医学模式相比,临床路径在提高医疗护理质量的同时,提高了团队协作,增加了患者本人的介入,使医疗护理更加合理化、人性化。临床路径的关键是达到医疗护理标准化,包括医疗团队的共识和循证医疗/护理。临床路径的应用是改善医疗、护理的持续活动,医生努力提高自身的诊断技术,熟悉手术前后的管理;护士按照临床路径执行护理,在执行中发现偏差并及时与医疗团队其他人员沟通,纠正偏差;药剂师、营养师等根据临床路径要求,同医生、护士互相协调;患者通过临床路径能够充分了解自己的病情,积极配合,最终使医疗护理质量提高,患者满意度提高。     

Medical errors,incidents, accidents and violations

Atul Gawande: 'The real problem isn't how to stop bad doctors from harming, even killing their patients. It's how to prevent good doctors from doing so.'A. Gawande: When doctors make mistakes. The New Yorker, 1st February 1999; 40-55.Errors are an integral part of human behaviour and performance, and in this respect, medical/ surgical practice is no exception. Undoubtedly medical errors account for substantial patient morbidity and mortality. The subject is complicated due to complex and at times confusing taxonomy and the lack of agreed definitions and classification of medical/ surgical errors. It is not possible to eliminate errors from clinical practice but we can improve the quality of medical care by adopting error-tolerant operating medical systems (E-TOMS) based on progress in cognitive psychology, human factors, and human reliability assessment made during the past 30 years. E-TOMS should enable detection, reporting and targeted reduction of errors, and together with effective team dynamics, good clinical governance incorporating root-cause analysis of adverse events during the delivery of health care should improve the quality of care that we can provide for our patients.     

Errors in laboratory medicine and patient safety: the road ahead.

The Institute of Medicine (IOM) report, To err is human, galvanized a dramatically increased level of concern about adverse events and patient safety in healthcare, including errors in laboratory medicine. While a significant decrease in the error rates of clinical laboratories has been achieved and documented in recent decades, available evidence demonstrates that the pre- and post-analytical phases of the total testing process are more vulnerable to errors than the analytical phase. However, analytical quality is still a major issue, particularly in some areas of laboratory medicine such as immunoassaying. In the present paper, current trends and factors that could effect future changes in the frequency and types of errors in laboratory services are analyzed and discussed. A more effective integration of automation and information technology could allow clinical laboratories to identify, control and decrease error rates in the total testing process, but interdepartmental cooperation and communication with clinicians and other stakeholders are essential to improving patient safety. Moreover, a fundamental shift in improving patient safety in laboratory medicine is to move from error reporting to risk management.     

Realising the developmental potential of Clinical Governance.

To be effective, Clinical Governance should reach all levels of a healthcare organisation. It requires structures and processes that integrate financial control, service performance, and clinical quality in ways that will engage clinicians and generate service improvements. The Clinical Governance arrangements of many Trusts, however, present several flaws. In particular, the "silos" organisational structure of Clinical Governance is based on generic issues such as risk management, clinical audit, clinical effectiveness and staff development, and it tends to treat clinical work as an undifferentiated aggregate. An alternative model focused on clinical pathways and on a balance between professional autonomy and accountability (responsible autonomy) should be promoted to make Clinical Governance work.     

Peer Coaching Integrated in Simulation: Improving Intraprofessional Teamwork

Poor communication in healthcare is recognized as a leading cause of medical errors. There is a call from national healthcare organizations for nursing education to focus on higher level competencies. Teamwork and collaboration is one of these competencies and should be a priority in nursing education. It is imperative that nurses function with open communication, mutual respect, and shared decision-making as members of the intra professional team. The traditional clinical practice setting is typically not conducive for an entire clinical group to fully practice these skills. Integrating peer coaching in simulation provides students with the opportunity to practice open communication, provide mutual respect, and share decision making to solve patient problems in a safe environment.     

呼吸机应用中的医疗风险及其防范

基于呼吸机建立的人工气道系统是一个多环节的复杂系统,存在高度不确定的应用风险性。建议将呼吸机应用中的质量控制纳入医院的医疗风险管理,实行呼吸机的专业化操作,培养业务精、懂管理、以医疗设备质量控制为重点的临床工程师参加呼吸机管理小组,制定规范的《呼吸机临床应用指南》、结合医院实际情况,建立行之有效的呼吸机风险监测与预警机制,将是减少或避免呼吸机导致的医疗事故发生的关键。     

Computer visualisation of patient safety in primary care: a systems approach adapted from management science and engineering

Patient safety and medical errors in ambulatory primary care are receiving increasing attention from policy makers, accreditation bodies and researchers, as well as by practising family physicians and their patients. While a great deal of progress has been made in understanding errors in hospital settings, it is important to recognise that ambulatory settings pose a very large and different set of challenges and that the types of hazards that exist and the strategies required to reduce them are very different. What is needed is a logical theoretical model for understanding the causes of errors in primary care, the role of healthcare systems in contributing to errors, the propagation of errors through complex systems and, importantly, for understanding ambulatory primary care in the context of the larger healthcare system. The authors have developed such a model using a formal 'systems engineering' approach borrowed from the management sciences and engineering. This approach has not previously been formally described in the medical literature.This paper outlines the formal systems approach, presents our visual model of the system, and describes some experiences with and potential applications of the model for monitoring and improving safety. Applications include providing a framework to help focus research efforts, creation of new (visual) error reporting and taxonomy systems, furnishing a common and unambiguous vision for the healthcare team, and facilitating retrospective and prospective analyses of errors and adverse events. It is aimed at system redesign for safety improvement through a computer-based patient-centred safety enhancement and monitoring instrument (SEMI-P). This model can be integrated with electronic medical records (EMRs).     

Potential errors and their prevention in operating room teamwork as experienced by Finnish, British and American nurses

This study describes how the potential sources of errors and error prevention in operating room (OR) teams are experienced by Finnish, American and British nurses. The data were collected by interviews and analysed using a qualitative content analysis. Results consisted of categories demanding teamwork practice, shared responsibility in teams and organized teamwork. The demanding practice category included fear of errors, turnover in teams, overtime work and emotional distress as potential factors leading to errors in OR teamwork. Shared responsibility emphasized how the familiar teams, safety control and formal documentation of errors prevented errors. At the organizational level, the prevention of errors required scheduling of work, good management, competency and a reasonable physical environment. In order to improve safety in OR teams, recognition should be given to the balance of error-making and learning from them. More effective ways in reporting incidents should be adopted and overall reporting systems should be developed in Finnish OR teams.     

Neuroscience critical care: the role of the advanced practice nurse in patient safety

The Institute of Medicine report published in 1999 described a healthcare system in which 44,000 to 98,000 patients die each year from preventable medical errors. The healthcare industry has been charged with identifying and ameliorating risks to patients. The advanced practice nurse is in the optimal position to influence the patient care environment and contribute to a culture of patient safety. This article will review the role of the advanced practice nurse in the care of the neuroscience patient in identifying risks unique to this at-risk population. There will be a discussion of risk factors that contribute to errors, with advanced practice nurse-driven, evidence-based solutions. A case presentation of the role of the advanced practice nurse in reducing the incidence of deep vein thrombosis in the craniotomy patients with malignant tumors will be discussed.     

The impact of pressure ulcer risk assessment on patient outcomes among hospitalised patients

Aims and objectives. To determine whether use of a risk assessment scale reduces nosocomial pressure ulcers. Background. There is contradictory evidence concerning the validity of risk assessment scales. The interaction of education, clinical judgement and use of risk assessment scales has not been fully explored. It is not known which of these is most important, nor whether combining them results in better patient care. Design. Pretest–posttest comparison. Methods. A risk assessment scale namely the Braden was implemented in a group of wards after appropriate education and training of staff in addition to mandatory wound care study days. Another group of staff received the same education programme but did not implement the risk assessment scale and a third group carried on with mandatory study days only. Results. Nosocomial Pressure Ulcer was reduced in all three groups, but the group that implemented the risk assessment scale showed no significant additional improvement. Allowing for age, gender, medical speciality, level of risk and other factors did not explain this lack of improvement. Clinical judgement seemed to be used by nurses to identify patients at high risk to implement appropriate risk reduction strategies such as use of pressure relieving beds. Clinical judgement was not significantly different from the risk assessment scale score in terms of risk evaluation. Conclusions. It is questioned whether the routine use of a risk assessment scale is useful in reducing nosocomial pressure ulcer. It is suggested clinical judgement is as effective as a risk assessment scale in terms of assessing risk (though neither show good sensitivity and specificity) and determining appropriate care. Relevance to clinical practice. Clinical judgement may be as effective as employing a risk assessment scale to assess the risk of pressure ulcers. If this were true it would be simpler and release nursing time for other tasks.     

An evaluation of adverse incident reporting

Abstract: To examine the reliability of adverse incident-reporting systems we carried out a retrospective review of the mother and baby case notes from a series of 250 deliveries in each of two London obstetric units. Notes were screened for the presence of adverse incidents defined by lists of incidents to be reported in accordance with unit protocols. We assessed the percentage of adverse incidents reported by staff to the maternity risk manager at each unit; the percentage of incidents detected by each risk manager, but not reported; and the percentage of incidents identified only by retrospective case note review. A total of 196 adverse incidents was identified from the 500 deliveries. Staff reported 23% of these and the risk managers identified a further 22%. The remaining 55% of incidents were identified only by retrospective case-note review and not known to the risk manager. Staff reported about half the serious incidents (48%), but comparatively few of the moderately serious (24%) or minor ones (15%). The risk managers identified an additional 16% of serious incidents that staff did not report. Drug errors were analysed separately; only two were known to the risk managers and a further 44 were found by case-note review. Incident-reporting systems may produce much potentially valuable information, but seriously underestimate the true level of reportable incidents. Where one risk manager covers an entire trust, rather than a single unit, reporting rates are likely to be very much lower than in the present study. Greater clarity is needed regarding the definition of reportable incidents (including drug errors). Staff should receive continuing education about the purposes and aims of clinical risk management and incident reporting and consideration should be given to designating specific members of staff with responsibility for reporting.     

Defensive medicine: It is time to finally slow down an epidemic

Defensive medicine is widespread and practiced the world over, with serious consequences for patients, doctors, and healthcare costs. Even students and residents are exposed to defensive medicine practices and taught to take malpractice liability into consideration when making clinical decisions. Defensive medicine is generally thought to stem from physicians’ perception that they can easily be sued by patients or their relatives who seek compensation for presumed medical errors. However, in our view the growth of defensive medicine should be seen in the context of larger changes in the conception of medicine that have taken place in the last few decades, undermining the patient–physician trust, which has traditionally been the main source of professional satisfaction for physicians. These changes include the following: time directly spent with patients has been overtaken by time devoted to electronic health records and desk work; family doctors have played a progressively less central role; clinical reasoning is being replaced by guidelines and algorithms; the public at large and a number of young physicians tend to believe that medicine is a perfect science rather than an imperfect art, as it continues to be; and modern societies do not tolerate the inevitable morbidity and mortality. To finally reduce the increasing defensive behavior of doctors around the world, the decriminalization of medical errors and the assurance that they can be dealt with in civil courts or by medical organizations in all countries could help but it would not suffice. Physicians and surgeons should be allowed to spend the time they need with their patients and should give clinical reasoning the importance it deserves. The institutions should support the doctors who have experienced adverse patient events, and the media should stop reporting with excessive evidence presumed medical errors and subject physicians to “public trials” before they are eventually judged in court.     

护士对惩罚性与无惩罚性差错管理方式认知和态度比较研究

目的:调查护士对惩罚性与无惩罚性差错管理方式的认知和态度,为建立无惩罚性自愿报告的差错管理制度提供研究依据。方法:对289名护理人员进行惩罚性与无惩罚性差错管理相关知识的认知及态度的问卷调查。结果:大部分护士对我国目前的护理差错管理方法比较了解,认为不能完全摒弃惩罚性管理方式,惩罚不一定能约束护士的行为且有可能影响差错报告的真实性;护士对无惩罚性自愿报告差错管理的目的及意义基本理解,对于实施无惩罚性自愿报告差错管理,大部分护士持肯定态度。结论:护理管理者应当充分认识护士对惩罚性与无惩罚性差错管理方式的认知与态度,积极倡导无惩罚自愿报告的差错管理方法,及时改进系统存在或潜在的安全问题,从而构建积极的护理安全文化。     

Using snowball sampling method with nurses to understand medication administration errors

Aims and objectives. We aimed to encourage nurses to release information about drug administration errors to increase understanding of error‐related circumstances and to identify high‐alert situations. Background. Drug administration errors represent the majority of medication errors, but errors are underreported. Effective ways are lacking to encourage nurses to actively report errors. Methods. Snowball sampling was conducted to recruit participants. A semi‐structured questionnaire was used to record types of error, hospital and nurse backgrounds, patient consequences, error discovery mechanisms and reporting rates. Results. Eighty‐five nurses participated, reporting 328 administration errors (259 actual, 69 near misses). Most errors occurred in medical surgical wards of teaching hospitals, during day shifts, committed by nurses working fewer than two years. Leading errors were wrong drugs and doses, each accounting for about one‐third of total errors. Among 259 actual errors, 83·8% resulted in no adverse effects; among remaining 16·2%, 6·6% had mild consequences and 9·6% had serious consequences (severe reaction, coma, death). Actual errors and near misses were discovered mainly through double‐check procedures by colleagues and nurses responsible for errors; reporting rates were 62·5% (162/259) vs. 50·7% (35/69) and only 3·5% (9/259) vs. 0% (0/69) were disclosed to patients and families. High‐alert situations included administration of 15% KCl, insulin and Pitocin; using intravenous pumps; and implementation of cardiopulmonary resuscitation (CPR). Conclusions. Snowball sampling proved to be an effective way to encourage nurses to release details concerning medication errors. Using empirical data, we identified high‐alert situations. Strategies for reducing drug administration errors by nurses are suggested. Relevance to clinical practice. Survey results suggest that nurses should double check medication administration in known high‐alert situations. Nursing management can use snowball sampling to gather error details from nurses in a non‐reprimanding atmosphere, helping to establish standard operational procedures for known high‐alert situations.     

Balancing Just Culture with regulatory standards

Over the past decade, there has been much attention called to the reality of errors occurring in healthcare that jeopardize patient safety. Not only has this attention and reality caused angst and concern for persons and families that may require healthcare but it also causes significant angst and concern among care providers themselves. In response to the reality that 44,000 to 98,000 deaths occur annually because of medical error, regulatory organizations developed standards to achieve compliance with safe practice and delivery of care and to increase accountability. To promote more open, consistent, and reporting without fear of retribution, Just Culture philosophies are increasingly evident in healthcare organizations. These Just Culture organizations are described as taking a fair and balanced approach to event reporting, learning from mistakes, and holding persons and the organization accountable.