错误部位疼痛管理程序发生率及根本原因分析：一项多中心研究。

Department of Anesthesiology and Critical Care Medicine, Blaustein Pain Treatment Center, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.

Anesthesiology. 2010 Mar;112(3):711-8. doi: 10.1097/ALN.0b013e3181cf892d.

BACKGROUND

Medical errors exact an inordinate toll on healthcare costs. One of the most publicized and analyzed type of medical error is wrong-site surgery. Yet, despite the burgeoning number of procedures performed, no literature exists on wrong-site pain management injections. The purpose of this study was to estimate the relative incidence and determine the causes of wrong-site pain management procedures.

METHODS

Quality improvement records were examined during a 2-yr period from four civilian academic teaching hospitals, three military treatment facilities, and three private practices, for "sentinel" events involving wrong-site pain management procedures. A total of 13 cases (incidence 0.027%; 95% CI 0.01-0.05%) were identified from approximately 48,941 collective procedures of which 52.4% were deemed to be "at risk" for the occurrence. Root cause analyses were then conducted to determine the origin of each error.

RESULTS

The 13 cases included five wrong-side transforaminal epidural steroid injections, six other wrong-side injections, and two wrong-level minimally invasive surgical procedures. In only one case was the "universal protocol" completely followed, and in nine procedures, multiple lapses occurred in protocol. Three patients had bilateral pathology, and in seven cases, the patient knew at the time that the wrong side was being injected. In no instance did any technical, legal, or professional consequences ensue from the error.

CONCLUSIONS

Wrong-site nerve blocks occur more frequently in pain management centers than has previously been acknowledged. Adaptation of the universal protocol to nerve blocks and strict adherence to widely accepted guidelines may prevent wrong-site interventional pain procedures.

背景

医疗差错给医疗成本造成了巨大的损失。最受关注和分析的医疗差错之一是手术部位错误。然而，尽管手术数量不断增加，但目前还没有关于错误部位疼痛管理注射的文献。本研究的目的是估计错误部位疼痛管理程序的相对发生率，并确定其原因。

方法

在四年间，从四家民营学术教学医院、三家军队医疗机构和三家私人诊所的质量改进记录中，对涉及错误部位疼痛管理程序的“哨兵”事件进行了检查。在大约 48941 例集体手术中，共发现了 13 例（发生率为 0.027%；95%CI0.01-0.05%），其中 52.4%被认为存在发生错误的风险。然后进行根本原因分析，以确定每个错误的来源。

结果

这 13 例包括 5 例错误侧经椎间孔硬膜外类固醇注射、6 例其他错误侧注射和 2 例错误水平微创手术。只有 1 例完全遵循了“通用协议”，9 例程序中协议多次出现失误。有 3 例患者有双侧病变，在 7 例病例中，患者在当时就知道注射的是错误的一侧。在任何情况下，错误都没有导致任何技术、法律或专业后果。