Wong David A, Herndon James H, Canale S Terry, Brooks Robert L, Hunt Thomas R, Epps Howard R, Fountain Steven S, Albanese Stephen A, Johanson Norman A
Denver Spine, Suite 100, 7800 East Orchard Road, Greenwood Village, CO 80111, USA.
J Bone Joint Surg Am. 2009 Mar 1;91(3):547-57. doi: 10.2106/JBJS.G.01439.
There has been widespread interest in medical errors since the publication of To Err Is Human: Building a Safer Health System by the Institute of Medicine in 2000. The Patient Safety Committee of the American Academy of Orthopaedic Surgeons has compiled the results of a member survey to identify trends in orthopaedic errors that would help to direct quality assurance efforts.
Surveys were sent to 5540 Academy fellows, and 917 were returned (a response rate of 16.6%), with 53% (483) reporting an observed medical error in the previous six months.
A general classification of errors showed equipment (29%) and communication (24.7%) errors with the highest frequency. Medication errors (9.7%) and wrong-site surgery (5.6%) represented serious potential patient harm. Two deaths were reported, and both involved narcotic administration errors. By location, 78% of errors occurred in the hospital (54% in the surgery suite and 10% in the patient room or floor). The reporting orthopaedic surgeon was involved in 60% of the errors; a nurse, in 37%; another orthopaedic surgeon, in 19%; other physicians, in 16%; and house staff, in 13%. Wrong-site surgeries involved the wrong side (59%); another wrong site, e.g., the wrong digit on the correct side (23%); the wrong procedure (14%); or the wrong patient (5% of the time). The most frequent anatomic locations were the knee and the fingers and/or hand (35% for each), the foot and/or ankle (15%), followed by the distal end of the femur (10%) and the spine (5%).
Medical errors continue to occur and therefore represent a threat to patient safety. Quality assurance efforts and more refined research can be addressed toward areas with higher error occurrence (equipment and communication) and high risk (medication and wrong-site surgery).
自2000年美国国家医学院发表《人皆有过：建立更安全的医疗体系》以来，医疗差错受到了广泛关注。美国矫形外科医师学会患者安全委员会汇总了一项会员调查结果，以确定矫形外科差错的趋势，从而有助于指导质量保证工作。
向5540名学会会员发送了调查问卷，回收917份（回复率为16.6%），其中53%（483份）报告在前六个月观察到医疗差错。
差错的总体分类显示，设备差错（29%）和沟通差错（24.7%）出现频率最高。用药差错（9.7%）和手术部位错误（5.6%）对患者有严重潜在危害。报告了两起死亡事件，均涉及麻醉用药差错。按发生地点划分，78%的差错发生在医院（54%发生在手术室，10%发生在病房或楼层）。报告差错的矫形外科医生参与了60%的差错；护士参与了37%；另一名矫形外科医生参与了19%；其他医生参与了16%；住院医生参与了13%。手术部位错误包括手术侧别错误（59%）；另一个错误部位，如正确侧别的错误手指（23%）；错误的手术操作（14%）；或错误的患者（5%）。最常见的解剖部位是膝关节以及手指和/或手部（各占35%）、足部和/或踝部（15%），其次是股骨远端（10%）和脊柱（5%）。
医疗差错仍在发生，因此对患者安全构成威胁。质量保证工作和更精细的研究可针对差错发生率较高的领域（设备和沟通）以及高风险领域（用药和手术部位错误）展开。
