Clarke J R, Spejewski B, Gertner A S, Webber B L, Hayward C Z, Santora T A, Wagner D K, Baker C C, Champion H R, Fabian T C, Lewis F R, Moore E E, Weigelt J A, Eastman A B, Blank-Reid C
Department of Surgery, MCP-Hahnemann University, Philadelphia, PA 19129, USA.
Acad Emerg Med. 2000 Nov;7(11):1303-10. doi: 10.1111/j.1553-2712.2000.tb00480.x.
A computer-based system to apply trauma resuscitation protocols to patients with penetrating thoracoabdominal trauma was previously validated for 97 consecutive patients at a Level 1 trauma center by a panel of the trauma attendings and further refined by a panel of national trauma experts. The purpose of this article is to describe how this system is now used to objectively critique the actual care given to those patients for process errors in reasoning, independent of outcome.
A chronological narrative of the care of each patient was presented to the computer program. The actual care was compared with the validated computer protocols at each decision point and differences were classified by a predetermined scoring system from 0 to 100, based on the potential impact on outcome, as critical/noncritical/no errors of commission, omission, or procedure selection.
Errors in reasoning occurred in 100% of the 97 cases studied, averaging 11.9/case. Errors of omission were more prevalent than errors of commission (2. 4 errors/case vs 1.2) and were of greater severity (19.4/error vs 5. 1). The largest number of errors involved the failure to record, and perhaps observe, beside information relevant to the reasoning process, an average of 7.4 missing items/patient. Only 2 of the 10 adverse outcomes were judged to be potentially related to errors of reasoning.
Process errors in reasoning were ubiquitous, occurring in every case, although they were infrequently judged to be potentially related to an adverse outcome. Errors of omission were assessed to be more severe. The most common error was failure to consider, or document, available relevant information in the selection of appropriate care.
先前已验证一种基于计算机的系统，该系统可将创伤复苏方案应用于穿透性胸腹联合伤患者。在一家一级创伤中心，由创伤主治医生小组对连续97例患者进行了验证，并由国家创伤专家小组进一步完善。本文的目的是描述该系统现在如何用于客观地评判给予这些患者的实际治疗中推理过程的错误，而不考虑结果。
向计算机程序提供每位患者治疗过程的按时间顺序的叙述。在每个决策点将实际治疗与经过验证的计算机方案进行比较，并根据对结果的潜在影响，通过预定的评分系统将差异分为0至100分，分为关键/非关键/无执行、遗漏或程序选择错误。
在研究的97例病例中，100%出现了推理错误，平均每例11.9次。遗漏错误比执行错误更普遍（2.4次/例对1.2次），且严重程度更高（19.4分/错误对5.1分）。错误数量最多的是未能记录，也许也未观察到与推理过程相关的床边信息，平均每位患者有7.4项缺失。10例不良结果中只有2例被判定可能与推理错误有关。
推理过程中的错误普遍存在，每个病例中都有发生，尽管它们很少被判定可能与不良结果有关。遗漏错误被评估为更严重。最常见的错误是在选择适当治疗时未能考虑或记录可用的相关信息。
