Cosby Karen S, Roberts Rebecca, Palivos Lisa, Ross Christopher, Schaider Jeffrey, Sherman Scott, Nasr Isam, Couture Eileen, Lee Moses, Schabowski Shari, Ahmad Ibrar, Scott R Douglas
Department of Emergency Medicine, Cook County Hospital, Rush Medical School, Chicago, IL 60612, USA.
Ann Emerg Med. 2008 Mar;51(3):251-61, 261.e1. doi: 10.1016/j.annemergmed.2007.06.483. Epub 2007 Oct 15.
We describe cases referred for physician review because of concern about quality of patient care and identify factors that contributed to patient care management problems.
We performed a retrospective review of 636 cases investigated by an emergency department physician review committee at an urban public teaching hospital over a 15-year period. At referral, cases were initially investigated and analyzed, and specific patient care management problems were noted. Two independent physicians subsequently classified problems into 1 or more of 4 major categories according to the phase of work in which each occurred (diagnosis, treatment, disposition, and public health) and identified contributing factors that likely affected outcome (patient factors, triage, clinical tasks, teamwork, and system). Primary outcome measures were death and disability. Secondary outcome measures included specific life-threatening events and adverse events. Patient outcomes were compared with the expected outcome with ideal care and the likely outcome of no care.
Physician reviewers identified multiple problems and contributing factors in the majority of cases (92%). The diagnostic process was the leading phase of work in which problems were observed (71%). Three leading contributing factors were identified: clinical tasks (99%), patient factors (61%), and teamwork (61%). Despite imperfections in care, half of all patients received some benefit from their medical care compared with the likely outcome with no care.
These reviews suggest that physicians would be especially interested in strategies to improve the diagnostic process and clinical tasks, address patient factors, and develop more effective medical teams. Our investigation allowed us to demonstrate the practical application of a framework for case analysis. We discuss the limitations of retrospective cases analyses and recommend future directions in safety research.
我们描述了因对患者护理质量的担忧而被提交给医生进行审查的病例，并确定了导致患者护理管理问题的因素。
我们对一家城市公立教学医院的急诊科医生审查委员会在15年期间调查的636例病例进行了回顾性审查。在转诊时，对病例进行了初步调查和分析，并记录了具体的患者护理管理问题。随后，两名独立的医生根据问题发生的工作阶段（诊断、治疗、处置和公共卫生）将问题分为4个主要类别中的1个或多个类别，并确定了可能影响结果的促成因素（患者因素、分诊、临床任务、团队合作和系统）。主要结局指标是死亡和残疾。次要结局指标包括特定的危及生命事件和不良事件。将患者结局与理想护理的预期结局以及无护理的可能结局进行了比较。
医生审查人员在大多数病例（92%）中发现了多个问题和促成因素。诊断过程是观察到问题的主要工作阶段（71%）。确定了三个主要促成因素：临床任务（99%）、患者因素（61%）和团队合作（61%）。尽管护理存在缺陷，但与无护理的可能结局相比，所有患者中有一半从医疗护理中获得了一些益处。
这些审查表明，医生对改善诊断过程和临床任务、解决患者因素以及建立更有效的医疗团队的策略会特别感兴趣。我们的调查使我们能够展示病例分析框架的实际应用。我们讨论了回顾性病例分析的局限性，并推荐了安全研究的未来方向。
