Rebasa Pere, Mora Laura, Luna Alexis, Montmany Sandra, Vallverdú Helena, Navarro Salvador
Corporacio Sanitària Parc Tauli, Parc Tauli s/n, 08208, Sabadell, Spain.
World J Surg. 2009 Feb;33(2):191-8. doi: 10.1007/s00268-008-9848-6.
This study was designed to determine the incidence of adverse events and errors in the care of surgical patients and to demonstrate that continuous prospective collection of data on adverse events can improve quality of care and reduce the number of errors. Retrospective studies find adverse events in approximately 5% of patients admitted. Prospective studies publish figures of approximately 30%. No studies to date have tried to use continuous collection of data on adverse events to reduce the incidence of errors.
Longitudinal prospective surveillance of adverse events in patients admitted to the Surgery Service during a 22-month period. Sequelae after discharge and errors during hospital stay were evaluated by peer review.
A total of 3,807 patients were controlled: 1,177 patients presented 2,193 adverse events (30.9% of admissions); 330 adverse events due to errors were detected in 258 patients (6.9% of admissions). Thirty-four deaths were considered due to adverse events (0.89% of admissions), and in 11 cases mortality was deemed avoidable (0.29% of admissions). The incidence of adverse events remained constant during the study period, but errors decreased from 11.1% to 4.5% (P = 0.005).
This is the first attempt to determine the prevalence of errors in surgery. Introducing systematic programs for recording adverse events can reduce error rates and promote a culture of patient safety in a General Surgery Department.
本研究旨在确定外科手术患者护理中不良事件和差错的发生率，并证明持续前瞻性收集不良事件数据可改善护理质量并减少差错数量。回顾性研究发现，约5%的入院患者发生不良事件。前瞻性研究公布的数据约为30%。迄今为止，尚无研究尝试通过持续收集不良事件数据来降低差错发生率。
对手术科室22个月期间入院患者的不良事件进行纵向前瞻性监测。出院后后遗症和住院期间差错通过同行评审进行评估。
共纳入3807例患者：1177例患者发生2193起不良事件（占入院患者的30.9%）；在258例患者中检测到330起因差错导致的不良事件（占入院患者的6.9%）。34例死亡被认为是由不良事件所致（占入院患者的0.89%），其中11例死亡被认为是可避免的（占入院患者的0.29%）。研究期间不良事件发生率保持不变，但差错率从11.1%降至4.5%（P = 0.005）。
这是首次尝试确定手术中差错的发生率。引入系统的不良事件记录程序可降低差错率，并在普通外科促进患者安全文化。
