Ther Clin Risk Manag. 2007 Aug;3(4):625-31.
We report a retrospective analysis of 84 consecutive pediatrics-related internal review files opened by a medical center's risk managers between 1996 and 2001. The aims were to identify common causative factors associated with adverse events/adverse outcomes (AEs) in a Pediatrics Department, then suggest ways to improve care. The main outcome was identification of any patterns of factors that contributed to AEs so that interventions could be designed to address them. Cases were noted to have at least one apparent contributing problem; the most common were with communication (44% of cases), diagnosis and treatment (37%), medication errors (20%), and IV/Central line issues (17%). 45% of files involved a child with an underlying diagnosis putting her/him at high risk for an adverse outcome. All Pediatrics Departments face multiple challenges in assuring consistent quality care. The extent to which the data generalize to other institutions is unknown. However, the data suggest that systematic analysis of aggregated claims files may help identify and drive opportunities for improvement in care.
我们对一家医疗中心风险管理人员在 1996 年至 2001 年间开启的 84 例儿科相关内部审查档案进行了回顾性分析。目的是确定儿科不良事件/不良结局（AE）相关的常见致病因素，然后提出改善护理的方法。主要结果是确定导致 AE 的因素模式，以便设计干预措施来解决这些问题。这些案例都有至少一个明显的致病问题；最常见的是沟通问题（占 44%）、诊断和治疗问题（37%）、用药错误问题（20%）以及静脉内/中央导管问题（17%）。45%的档案涉及患有潜在疾病的儿童，这些儿童有发生不良后果的高风险。所有儿科部门在确保一致的高质量护理方面都面临着多重挑战。这些数据在多大程度上适用于其他机构尚不清楚。然而，数据表明，对汇总理赔档案进行系统分析可能有助于识别和推动护理改进的机会。
