错误患者成像顺序错误的回顾性队列研究:有多少人到达患者?
Jerard Z Kneifati-Hayek1, Elias Geist2, Jo R Applebaum1
1Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA.
BMJ quality & safety
|December 10, 2023
概括
医疗成像中几乎错过的错误对于防止患者受到伤害至关重要. 这项研究发现,对于每一次到达患者的错误,就会发生50次近乎失误事件,这凸显了跟踪这些近乎失误事件的价值.
科学领域:
- 医学错误分析 医学错误分析
- 患者安全研究的研究.
- 放射学和成像信息学
背景情况:
- 差点错误是防止患者受到伤害的关键指标.
- 到达患者的误差估计差异很大,需要可靠的测量.
- 了解差点失误和实际错误之间的关系对于干预至关重要.
研究的目的:
- 估计被拦截的错误患者成像顺序错误 (近乎错误) 与到达患者的错误的比例.
- 利用客观的措施来识别和量化错误的病人成像订单错误涉及辐射.
- 为了提供一个更准确,更可靠的估计接近失误到错误比率.
主要方法:
- 在一个大型综合医疗保健系统进行的回顾性队列研究.
- 从2019年1月1日至12月31日收集的所有涉及辐射的成像订单的数据.
- 使用了两个结果指标:纽约患者事件报告和跟踪系统 (NYPORTS) 错误的管理事件和错误的患者撤回和重新安排 (RAR) 几乎错误的事件.
主要成果:
- 总共分析了293,039个符合条件的成像订单.
- 确定了151个错误的病人订单:3个错误的管理事件和148个几乎错误的事件.
- 涉及辐射的错误患者成像订单的总比率为每10万个订单中的51.5个.
- 只有2%的错误患者成像顺序错误到达了患者,这表明每到达患者的1个错误,就有50次近乎错误事件.
结论:
- 错误的病人成像订单中的近乎错误的错误比到达患者的错误更为常见.
- 系统地测量近乎失误的错误是评估预防干预措施的有价值结果.
- 这些发现强化了近乎失误错误分析在改善放射学患者安全方面的重要性.
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