家庭官员是否从错误中吸取教训?
A W Wu1, S Folkman, S J McPhee
1Department of Veterans Affairs, University of California, San Francisco.
JAMA
|April 24, 1991
概括
医疗错误在内部医学院官员中很常见,往往导致严重的患者伤害. 讨论错误和承担责任鼓励建设性实践变化,而工作量和机构判断影响居民的反应.
科学领域:
- 医学教育 医学教育
- 患者安全 患者安全
- 医疗保健的质量 医疗保健的质量
背景情况:
- 医疗错误是医疗保健提供不可避免的方面.
- 了解医疗错误与实践修改之间的联系对于改善患者的治疗结果至关重要.
- 内部医学院的官员是研究错误报告和学习的关键人口.
研究的目的:
- 调查内部医学院官员犯下的医疗错误与其后的医疗实践变化之间的关系.
- 确定影响住房官员对错误反应的因素,包括与同行和监督人员的讨论,以及患者/家庭沟通.
- 探索感知工作量和机构文化对错误报告和学习的影响.
主要方法:
- 匿名问卷调查对254名内部医学院官员进行了调查.
- 114名房屋管理员 (45%) 完成了调查,详细介绍了他们最严重的错误和他们的回应.
- 收集关于错误类型,患者结果和沟通模式的数据.
主要成果:
- 错误包括诊断 (33%),处方 (29%),评估 (21%),沟通 (5%) 和程序并发症 (11%).
- 在90%的病例中,患者出现了严重的不良结果,其中31%的病例死亡.
- 只有54%的人与主治医生讨论了错误;24%的患者/家属被告知. 接受责任和讨论与建设性实践变化相关.
结论:
- 接受责任并讨论错误的众议院官员更有可能实施建设性的实践变化.
- 工作超载与较少的建设性变化有关,而判断性的机构环境导致了防御性的变化.
- 减少工作量,加强监督,培养鼓励公开讨论错误的环境,对于医学学习和预防未来错误至关重要.
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