Singh Hardeep, Thomas Eric J, Petersen Laura A, Studdert David M
Health Policy and Quality Program, Houston Center for Quality of Care and Utilization Studies, Houston, Texas, USA.
Arch Intern Med. 2007 Oct 22;167(19):2030-6. doi: 10.1001/archinte.167.19.2030.
Despite wide recognition that the delivery of medical care by trainees involves special risks, information about the types and causes of medical errors involving trainees is limited. To describe the characteristics of and factors contributing to trainee errors, we analyzed malpractice claims in which trainees were judged to have played an important role in harmful errors.
The claims were closed between 1984 and 2004, and the errors occurred between 1979 and 2001. Specialist physicians reviewed random samples of closed malpractice claim files at 5 liability insurers from 2002 to 2004 and determined whether injuries had occurred, and if so, whether they were due to error. We described the clinical circumstances and contributing factors associated with harmful errors involving trainees ("cases"). We also compared the characteristics of cases with their nontrainee counterparts and probed trainee errors attributed to teamwork problems and lack of technical competence or knowledge.
Among 240 cases, errors in judgment (173 of 240 [72%]), teamwork breakdowns (167 of 240 [70%]), and lack of technical competence (139 of 240 [58%]) were the most prevalent contributing factors. Lack of supervision and handoff problems were most prevalent types of teamwork problems, and both were disproportionately more common among errors that involved trainees than those that did not (respectively, 54% vs 7% [P < .001] and 20% vs 12% [P = .009]). The most common task during which failures of technical competence occurred were diagnostic decision making and monitoring of the patient or situation. Trainee errors appeared more complex than nontrainee errors (mean of 3.8 contributing factors vs 2.5 [P < .001]).
In addition to problems with handoffs, house staff are particularly vulnerable to medical errors owing to teamwork failures, especially lack of supervision. Graduate medical education reform should focus on strengthening these aspects of training.
尽管人们普遍认识到实习医生提供医疗服务存在特殊风险，但有关实习医生医疗差错的类型和原因的信息有限。为了描述实习医生差错的特征及促成因素，我们分析了那些判定实习医生在有害差错中起重要作用的医疗事故索赔案例。
这些索赔案例于1984年至2004年结案，差错发生在1979年至2001年期间。2002年至2004年，专科医生对5家责任保险公司的已结案医疗事故索赔档案随机抽样进行审查，确定是否发生了伤害，如果发生了，是否是由差错导致的。我们描述了与涉及实习医生的有害差错（“案例”）相关的临床情况和促成因素。我们还比较了案例与非实习医生对应案例的特征，并探究了归因于团队协作问题以及缺乏技术能力或知识的实习医生差错。
在240个案例中，判断失误（240例中的173例[72%]）、团队协作失败（240例中的167例[70%]）和缺乏技术能力（240例中的139例[58%]）是最常见的促成因素。缺乏监督和交接班问题是最常见的团队协作问题类型，在涉及实习医生的差错中，这两种问题都比不涉及实习医生的差错更为常见（分别为54%对7%[P <.001]和20%对12%[P =.009]）。技术能力出现失误最常见的任务是诊断决策以及对患者或情况的监测。实习医生的差错似乎比非实习医生的差错更为复杂（促成因素的平均数为3.8个对2.5个[P <.001]）。
除了交接班问题外，住院医生尤其容易因团队协作失败，特别是缺乏监督而出现医疗差错。毕业后医学教育改革应侧重于加强培训的这些方面。
