急診中發生的多數錯誤是人為引起的

作者：Fran Lowry  
出處：WebMD醫學新聞

　　September 17, 2009 — 根據線上發表於9月18日BMC Emergency Medicine期刊的研究，急診中發生之多數影響病患安全的錯誤是人為疏失引起的。
　　
　　荷蘭健康服務研究中心的Marleen Smits醫師等人寫道，急診是醫院中攸關病患安全的部門。極需採取有效策略以改善病患安全，這唯有對潛在原因採取因應措施才可達成。
　　
　　研究目標是檢視急診異常事件的本質與原因，以及探討事件類型和原因架構之間的關係。
　　
　　該研究評估了荷蘭10家醫院(1所大學醫院、3家3級教學醫院、6家一般醫院)急診室的醫療疏失，為期8至10週。要求急診工作人員報告所有的異常事件，不論多瑣碎或平常，都可能有傷害或對病患產生傷害。
　　
　　總共有522個事件報告，每個急診的事件數從46至71件，平均有52件報告。多數報告(85%)由護士提出；住院醫師或會診醫師提出13%的異常事件、書記人員提出的有2%。這些報告中有83%直接與異常事件有關。多數發生在日間(44%)；34%發生在傍晚和夜間，有22%異常事件的發生時間未知或未載明。
　　
　　Smits醫師等人寫道，多數錯誤發生在醫療檢查或檢驗時(36%)。超過半數的異常事件(56%)造成病患受到影響，其中的45%，病患因而遭受某種不便，例如延長等候時間。三分之一的病患因而接受了不適當的照護，例如延遲了開始抗生素治療的時間。因錯誤而造成的影響中，比較嚴重的有8%的病患需要額外的介入處置、6%的病患遭受疼痛、3%的病患身體受到傷害。
　　
　　錯誤的根本原因，多數是人為的(60%)，其次為機構面的(25%)與技術面的(11%)原因。將近半數的根本原因是由於院內外的其他部門造成。
　　
　　至於他們的研究限制，研究者指出，因為報告不是匿名的，可能有某些錯誤未被提出。這可能使結果有偏差，傾向報告較不嚴重的事件、對病患沒有後遺症的事件、其他部門引起的事件等，因為這些算是「比較安全的」報告。
　　
　　此外，多數錯誤是由護士報告，因此研究結果可能會給人這些事件主要是與護理照護有關、與急診住院醫師和專家較無關的印象。
　　
　　作者們寫道，雖然多數的錯誤對病患沒有產生後遺症，或只造成些微不便，但這些錯誤累積起來對病患的健康影響也是很大的。他們結論表示，事件報告可以對異常事件有所瞭解。異常事件的資訊有助於增加病患安全的研究與介入。急診與醫院其他部門合作的直接介入方式看來是值得採行的。
　　
　　Smits醫師等人皆宣告沒有相關財務關係。
　　
　　BMC Emerg Med. 線上發表於2009年9月18日。

Most Mistakes in the Emergency Department Caused by Human Error

By Fran Lowry
Medscape Medical News

September 17, 2009 — Most of the mistakes in the emergency department (ED) that have the potential to compromise patient safety are caused by human error, according to a study published online September 18 in BMC Emergency Medicine.

"[EDs] are challenging hospital settings with regard to patient safety. There is an increased sense of urgency to take effective countermeasures in order to improve patient safety," Marleen Smits, MD, from the Netherlands Institute for Health Services Research, Utrecht, and colleagues write. "This can only be achieved if interventions tackle the dominant underlying causes."

The aim of this study was to examine the nature and causes of unintended events in EDs and the relationship between type of event and causal factor structure.

The study evaluated medical errors in the EDs of 10 hospitals in the Netherlands (1 university hospital, 3 tertiary teaching hospitals, and 6 general hospitals) for 8 to 10 weeks. ED staff members were asked to report all unintended events, no matter how trivial or commonplace, that could have harmed or did harm a patient.

A total of 522 events were reported, ranging from 46 to 71 per ED, for an average of 52 reports. Most of the reports (85%) were made by nurses; resident physicians or consultants reported 13% of the unintended events, and clerical staff reported 2%. The reporter was directly involved in 83% of the unintended events. Most occurred during daytime hours (44%); 34% occurred during evening and night, and for 22% of the unintended events, the time of occurrence was unknown or unspecified by the reporter.

Most errors occurred during medical examinations or lab tests (36%). More than half of the unintended events (56%) had consequences for the patient, and in 45% of these instances, the patient suffered some inconvenience, such as prolonged waiting time. One third of patients received suboptimal care, such as a delay in starting antibiotic treatment. The consequences of error were more severe in the 8% of patients who required an extra intervention, the 6% of patients who suffered pain, and the 3% of patients who suffered a physical injury, Dr. Smits and colleagues write.

Most root causes of error were human (60%), followed by organizational (25%) and technical (11%) causes. Nearly half of the root causes could be attributed to other departments either in or outside of the hospital.

In citing limitations to their study, the investigators note that, because the reporting was not anonymous, it is possible that certain mistakes were underreported. "This may have biased the results towards the reporting of less significant events, events without consequences for the patient, and errors originating in other departments, because these are 'safer' to report."

In addition, most errors were reported by nurses, and therefore the study results give information about events that are mainly related to nursing care and less to care by residents and specialists in the ED.

Although the majority of errors had no consequences for the patient or resulted in only minor inconveniences, their accumulated effect on patient well-being is likely to be large, the authors write. They conclude: "Event reporting gives insight into diverse unintended events. The information on unintended events may help target research and interventions to increase patient safety. It seems worthwhile to direct interventions on the collaboration between the ED and other hospital departments."

Dr. Smits and colleagues have disclosed no relevant financial relationships.

BMC Emerg Med. Published online September 18, 2009.