Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
Prehosp Emerg Care. 2011 Jan-Mar;15(1):39-43. doi: 10.3109/10903127.2011.519817. Epub 2010 Oct 29.
Communication errors are a source of preventable medical errors. In high-risk health care settings, identifying the source and addressing root causes can reduce error and improve patient safety. While air medical transport is a high-risk setting, its sources and rates of error have been investigated only within the last several years.
This investigation examined the rate and types of communication errors during call booking of interfacility air medical transports. The primary objective was to determine the incidence and type of errors when the initial requests for transfer took place between the sending facility and transport medicine communication center. The secondary objective was to identify potential underlying causes of these errors.
Requests for urgent and emergent interfacility air medical transfers were examined prospectively during a consecutive two-week period. As the first step in call booking, sending facility staff speak directly to communication center staff and are asked for administrative, demographic, and medical details to determine patient acuity and call priority. After this information was captured, investigators contacted the sending facility to verify the information and identify any communication errors. Errors were classified as major (potentially impacting care) or minor (unlikely to impact care) and as errors of omission or commission. Common error types were presented to a management focus group to identify potential contributing causes for these errors.
One hundred twelve calls were randomly selected during the study period, with 98 meeting study criteria. Of those, 41 (42%) calls contained a total of 65 errors. Eleven were classified as major, including five errors of omission and six errors of commission. The most common major errors were recording "no drug allergies" when a drug allergy was present (n = 4), incorrect diagnosis (n = 2), and failure to record that patients were intubated or required mechanical ventilation (n = 2 each). There were 54 minor errors, including 41 omission errors and 13 commission errors. Nearly half the errors were attributed to procedures and software. No identified error resulted in patient harm or an adverse outcome.
Communication-based errors are common in the initial phases of call booking in air medical transport. Human and process-driven errors contribute equally to these errors.
沟通错误是可预防的医疗错误的一个来源。在高风险的医疗保健环境中，确定来源并解决根本原因可以减少错误并提高患者安全性。虽然航空医疗运输是一个高风险的环境，但对其错误的来源和发生率的研究仅在过去几年进行。
本研究调查了在院际空中医疗转运的呼叫预订过程中沟通错误的发生率和类型。主要目的是确定在发送机构与运输医学通信中心之间进行初始转院请求时出现错误的发生率和类型。次要目的是确定这些错误的潜在根本原因。
在连续两周的时间内，前瞻性地检查了紧急和紧急院际空中医疗转运的请求。作为呼叫预订的第一步，发送机构的工作人员直接与通信中心的工作人员交谈，并被要求提供行政、人口统计学和医疗细节，以确定患者的病情严重程度和呼叫优先级。在获取此信息后，调查人员联系发送机构以验证信息并确定任何沟通错误。错误分为主要（可能影响护理）或次要（不太可能影响护理），以及遗漏或遗漏错误。向管理重点小组介绍常见的错误类型，以确定这些错误的潜在促成因素。
在研究期间随机选择了 112 个呼叫，其中 98 个符合研究标准。在这些呼叫中，有 41 个（42%）呼叫共包含 65 个错误。其中 11 个被归类为主要错误，包括 5 个遗漏错误和 6 个错误。最常见的主要错误是记录“无药物过敏”而实际上存在药物过敏（n = 4），错误诊断（n = 2）以及未能记录患者插管或需要机械通气（n = 2）。有 54 个次要错误，包括 41 个遗漏错误和 13 个错误。近一半的错误归因于程序和软件。没有识别出导致患者伤害或不良后果的错误。
在航空医疗转运的呼叫预订初期，基于沟通的错误很常见。人为和流程驱动的错误对等贡献于这些错误。
