Snijders C, van der Schaaf T W, Klip H, van Lingen R A, Fetter W P F, Molendijk A
Haga Hospital, Location Juliana Children's Hospital, Sportlaan 600, 2566 MJ The Hague, The Netherlands.
Qual Saf Health Care. 2009 Dec;18(6):486-91. doi: 10.1136/qshc.2008.028068.
In this study, the feasibility and reliability of the Prevention Recovery Information System for Monitoring and Analysis (PRISMA)-Medical method for systematic, specialty-based analysis and classification of incidents in the neonatal intensive care unit (NICU) were determined.
After the introduction of a Neonatology System for Analysis and Feedback on Medical Events (NEOSAFE) in eight tertiary care NICUs and one paediatric surgical ICU, PRISMA-Medical was started to be used to identify root causes of voluntary reported incidents by multidisciplinary unit patient safety committees. Committee members were PRISMA-trained and familiar with the department and its processes. In this study, the results of PRISMA-analysis of incidents reported during the first year are described. At t = 3 months and t = 12 months after introduction, test cases were performed to measure agreement at three levels of root cause classification using PRISMA-Medical. Inter-rater reliability was determined by calculating generalised kappa values for each level of classification.
During the study period, 981 out of 1786 eligible incidents (55%) were analysed for underlying root causes. In total, 2313 root causes were identified and classified, giving an average of 2.4 root causes for every incident. Although substantial agreement (kappa 0.70-0.81) was reached at the main level of root cause classification of the test cases (discrimination between technical, organisational and human failure) and agreement among the committees at the second level (discrimination between skill-based, rule-based and knowledge-based errors) was acceptable (kappa 0.53-0.59), discrimination between rule-based errors (the third level of classification) was more difficult to assess (kappa 0.40-0.47).
With some restraints, PRISMA-Medical proves to be both feasible and acceptably reliable to identify and classify multiple causes of medical events in the NICU.
在本研究中，确定了用于新生儿重症监护病房（NICU）事件的系统的、基于专业的分析和分类的预防恢复信息监测与分析系统（PRISMA）-医学方法的可行性和可靠性。
在八个三级护理NICU和一个儿科外科ICU引入了医疗事件分析与反馈新生儿系统（NEOSAFE）后，开始使用PRISMA-医学来识别多学科单位患者安全委员会自愿报告事件的根本原因。委员会成员接受了PRISMA培训，熟悉科室及其流程。在本研究中，描述了第一年报告事件的PRISMA分析结果。在引入后3个月和12个月时，进行测试案例以使用PRISMA-医学在根本原因分类的三个层面测量一致性。通过计算每个分类层面的广义kappa值来确定评分者间信度。
在研究期间，对1786起符合条件的事件中的981起（55%）分析了潜在根本原因。总共识别并分类了2313个根本原因，平均每个事件有2.4个根本原因。虽然在测试案例的根本原因分类主要层面（技术、组织和人为失误之间的区分）达成了实质性一致（kappa 0.70 - 0.81），并且委员会在第二层面（基于技能、基于规则和基于知识的错误之间的区分）的一致性是可接受的（kappa 0.53 - 0.59），但基于规则的错误之间的区分（分类的第三层面）更难评估（kappa 0.40 - 0.47）。
尽管存在一些限制，但PRISMA-医学被证明在识别和分类NICU中医疗事件的多种原因方面既可行又具有可接受的可靠性。
