诊断过程中的错误和缺陷模式:从两个国家数据库中对不良做法和不良事件的索赔进行了回顾性分析
Siri Tribler1, Charlotte Frendved2, Eva Benfeldt3
1Danish Society for Patient Safety, Frederiksberg, Denmark siri.tribler@patientsikkerhed.dk.
诊断错误 (DEs) 是一个重要的患者安全问题. 这项研究发现,DEs在丹麦医疗保健中很普遍,初步评估和后续行动是需要改进的关键脆弱步骤.
科学领域:
- 医疗保健的质量和安全
- 医学错误分析 医学错误分析
- 患者危害评估 患者危害评估
背景情况:
- 诊断错误 (DEs) 是全球主要的患者安全问题,导致发病率和死亡率增加.
- 了解DE和相关不良事件的发生对于识别患者伤害和过程漏洞至关重要.
研究的目的:
- 调查在丹麦医疗保健中诊断错误和不良事件的流行情况.
- 识别诊断过程中的脆弱阶段,这些阶段有助于DES和患者伤害.
主要方法:
- 国家数据库的回顾性分析:国家医疗保健赔偿索赔数据库 (2009-2018) 和丹麦患者安全数据库 (2015-2020).
- 利用控制风险保险公司的评分工具来识别脆弱的诊断步骤.
主要成果:
- 损失事故占已解决赔偿索赔的14.5%,赔偿率为59%,与较高的死亡率和残疾相关.
- 报告的AE的0.3%是致命的,每年1.7%造成严重伤害;33%的严重/致命AE被归因于DE.
- 最初的临床评估 (80-83%) 和随访/协调 (33-46%) 被确定为导致DEs和严重的副作用的关键因素.
结论:
- 诊断错误和有害事件在丹麦医疗保健中构成了重大患者安全挑战.
- 已经确定了诊断过程中的脆弱步骤,与严重程度相关.
- 需要对临床评估和随访进行有针对性的改进,以减轻DE风险.
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