Wu A W, Folkman S, McPhee S J, Lo B
Department of Veterans Affairs, University of California, San Francisco.
JAMA. 1991 Apr 24;265(16):2089-94.
Mistakes are inevitable in medicine. To learn how medical mistakes relate to subsequent changes in practice, we surveyed 254 internal medicine house officers. One hundred fourteen house officers (45%) completed an anonymous questionnaire describing their most significant mistake and their response to it. Mistakes included errors in diagnosis (33%), prescribing (29%), evaluation (21%), and communication (5%) and procedural complications (11%). Patients had serious adverse outcomes in 90% of the cases, including death in 31% of cases. Only 54% of house officers discussed the mistake with their attending physicians, and only 24% told the patients or families. House officers who accepted responsibility for the mistake and discussed it were more likely to report constructive changes in practice. Residents were less likely to make constructive changes if they attributed the mistake to job overload. They were more likely to report defensive changes if they felt the institution was judgmental. Decreasing the work load and closer supervision may help prevent mistakes. To promote learning, faculty should encourage house officers to accept responsibility and to discuss their mistakes.
医学中错误在所难免。为了解医疗错误与后续实践变化之间的关系，我们对254名内科住院医师进行了调查。114名住院医师（45%）完成了一份匿名问卷，描述了他们最严重的错误以及对此的应对措施。错误包括诊断错误（33%）、开方错误（29%）、评估错误（21%）、沟通错误（5%）以及操作并发症（11%）。90%的病例中患者出现了严重不良后果，其中31%的病例导致死亡。只有54%的住院医师与他们的主治医生讨论了错误，只有24%告知了患者或家属。对错误承担责任并进行讨论的住院医师更有可能报告实践中的建设性变化。如果住院医师将错误归因于工作负担过重，他们进行建设性改变的可能性较小。如果他们觉得机构爱评判，就更有可能报告防御性改变。减轻工作量和加强监督可能有助于预防错误。为促进学习，教员应鼓励住院医师承担责任并讨论他们的错误。
