Pichlmaier H, Thul P
Klinik und Poliklinik für Chirurgie, Köln.
Langenbecks Arch Chir Suppl II Verh Dtsch Ges Chir. 1990:1303-8.
Looking for medical errors in clinical practice we reviewed several cases from our daily indication and case conference, 6 cases discussed in the lethality conference and 9 which were treated by legal institutions. The points of criticism were analysed. We discriminated between diagnostic, therapeutic failures and those of organisation. The basis were 4045 patients with 4583 operations during the year 1989. The overall lethality was 1.2%. The instruments of avoiding medical errors in individual and general sense were shown.
为了在临床实践中查找医疗差错,我们回顾了日常诊疗及病例讨论中的几个病例、在死亡讨论会上讨论的6个病例以及由法律机构处理的9个病例。对批评要点进行了分析。我们区分了诊断失误、治疗失误和组织失误。依据是1989年的4045例患者及4583台手术。总体死亡率为1.2%。展示了在个体和总体层面避免医疗差错的方法。