Shah Rahul K, Lander Lina, Forbes Peter, Jenkins Kathy, Healy Gerald B, Roberson David W
Division of Otolaryngology, Children's National Medical Center, George Washington University School of Medicine, Washington, DC 20010, USA.
Laryngoscope. 2009 May;119(5):871-9. doi: 10.1002/lary.20208.
Studies of medical error demonstrate that errors and adverse events (AEs) are common in hospitals. There are little data of errors on pediatric surgical services.
We retrospectively reviewed 50 randomly selected inpatient admissions to the otolaryngology service at a tertiary care children's hospital. We used a "zero-defect" paradigm, recording any error or adverse event-from minor errors such as illegible notes to more significant errors such as mismanagement resulting in a bleeding emergency.
A total of 553 errors/AEs were identified in 50 admissions. Most (449) were charting or record-keeping deficiencies. Minor AEs (n = 26) and moderate AEs (n = 8) were present in 38% of admissions; there were no major AEs or permanent morbidity. Medication-related errors occurred in 22% of admissions, but only two resulted in minor AEs. There was a positive correlation between minor errors and AEs; however, this was not statistically significant.
Multiple errors occurred in every inpatient pediatric otolaryngology admission; however, only 26 minor and eight moderate AEs were identified. The rate of errors per 1,000 hospital days (6,356 per 1,000 days) is higher than previously reported in voluntary reporting studies, possibly due to our methodology of physician review with a "zero-defect" standard. Trends in the data suggest that the presence of small errors may be associated with the risk of adverse events. Although labor-intensive, physician chart review is a valuable tool for identifying areas for improvement. Although small errors were common, there were few harms and no major morbidity.
医疗差错研究表明，差错和不良事件（AE）在医院中很常见。关于小儿外科服务差错的数据很少。
我们回顾性地随机选取了一家三级儿童专科医院耳鼻喉科的50例住院病例。我们采用“零缺陷”模式，记录任何差错或不良事件——从诸如字迹潦草的小差错到诸如导致出血紧急情况的管理不善等更严重的差错。
在50例住院病例中共识别出553起差错/不良事件。大多数（449起）是图表记录或保存方面的缺陷。38%的住院病例出现了轻微不良事件（n = 26）和中度不良事件（n = 8）；没有重大不良事件或永久性发病情况。22%的住院病例发生了与用药相关的差错，但只有两起导致了轻微不良事件。小差错和不良事件之间存在正相关；然而，这在统计学上并不显著。
每例小儿耳鼻喉科住院病例都发生了多起差错；然而，仅识别出26起轻微不良事件和8起中度不良事件。每1000个住院日的差错率（每1000天6356起）高于之前自愿报告研究中的报告率，这可能是由于我们采用了“零缺陷”标准的医生审查方法。数据趋势表明，小差错的存在可能与不良事件风险相关。尽管医生审查图表需要耗费大量人力，但它是识别改进领域的宝贵工具。虽然小差错很常见，但危害很少，也没有重大发病情况。
