Smits M, Zegers M, Groenewegen P P, Timmermans D R M, Zwaan L, van der Wal G, Wagner C
NIVEL, Netherlands Institute for Health Services Research, PO Box 1568, 3500 BN Utrecht, The Netherlands.
Qual Saf Health Care. 2010 Oct;19(5):e5. doi: 10.1136/qshc.2008.030726. Epub 2010 Feb 8.
To examine the causes of adverse events (AEs) and potential prevention strategies to minimise the occurrence of AEs in hospitalised patients.
For the 744 AEs identified in the patient record review study in 21 Dutch hospitals, trained reviewers were asked to select all causal factors that contributed to the AE. The results were analysed together with data on preventability and consequences of AEs. In addition, the reviewers selected one or more prevention strategies for each preventable AE. The recommended prevention strategies were analysed together with four general causal categories: technical, human, organisational and patient-related factors.
Human causes were predominantly involved in the causation of AEs (in 61% of the AEs), 61% of those being preventable and 13% leading to permanent disability. In 39% of the AEs, patient-related factors were involved, in 14% organisational factors and in 4% technical factors. Organisational causes contributed relatively often to preventable AEs (93%) and AEs resulting in permanent disability (20%). Recommended strategies to prevent AEs were quality assurance/peer review, evaluation of safety behaviour, training and procedures. For the AEs with human and patient-related causes, reviewers predominantly recommended quality assurance/peer review. AEs caused by organisational factors were considered preventable by improving procedures.
Healthcare interventions directed at human causes are recommended because these play a large role in AE causation. In addition, it seems worthwhile to direct interventions on organisational causes because the AEs they cause are nearly always believed to be preventable. Organisational factors are thus relatively easy to tackle. Future research designs should allow researchers to interview healthcare providers that were involved in the event, as an additional source of information on contributing factors.
探讨不良事件（AE）的原因及潜在预防策略，以尽量减少住院患者中AE的发生。
对于在荷兰21家医院的患者病历回顾研究中识别出的744例AE，要求经过培训的评审人员选择所有导致AE的因果因素。将结果与AE的可预防性和后果数据一起进行分析。此外，评审人员为每个可预防的AE选择一种或多种预防策略。对推荐的预防策略与四个一般因果类别进行分析：技术、人为、组织和患者相关因素。
人为因素在AE的发生中占主导地位（61%的AE），其中61%是可预防的，13%导致永久性残疾。在39%的AE中涉及患者相关因素，14%涉及组织因素，4%涉及技术因素。组织原因相对经常导致可预防的AE（93%）和导致永久性残疾的AE（20%）。预防AE的推荐策略是质量保证/同行评审、安全行为评估、培训和程序。对于由人为和患者相关原因导致的AE，评审人员主要推荐质量保证/同行评审。由组织因素导致的AE被认为可通过改进程序来预防。
建议针对人为原因进行医疗保健干预，因为这些在AE的发生中起很大作用。此外，针对组织原因进行干预似乎是值得的，因为它们导致的AE几乎总是被认为是可预防的。因此，组织因素相对容易解决。未来的研究设计应允许研究人员采访参与该事件的医疗保健提供者，作为关于促成因素的额外信息来源。
