Center for Patient Safety Research and Practice, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts 02120, USA.
JAMA. 2011 May 11;305(18):1890-8. doi: 10.1001/jama.2011.496. Epub 2011 Apr 12.
Mr B, a 60-year-old man with back pain, was not informed of an incidental finding of a renal mass suggestive of cancer on a magnetic resonance imaging scan. Failure and delays in test follow-up are a frequent problem in medicine, occurring in more than 5% of significantly abnormal ambulatory test results. Rather than simply blaming involved clinicians, systems for managing tests need to be reengineered using methods from reliability sciences. These begin with investigations into the systemic causes of the failures, then application of approaches such as heightened situational awareness, closed-loop systems, improved handoffs, just-in-time work, culture and practices of stopping to fix problems, forcing functions and simplification, enhanced visual cues, and cautious use of information technology and redundancy, all while avoiding suboptimization. Emerging test management systems and critical test follow-up recommendations illustrate how applying these principles can enhance this important aspect of patient safety.
患者 B 先生，60 岁，背痛，磁共振成像扫描发现肾脏有疑似癌症的肿块，但并未被告知这一偶然发现。检测结果的跟踪工作失败和延误在医学中是一个常见问题，超过 5%的门诊检测结果异常都会出现这种情况。对于这种情况，我们不应该简单地指责相关临床医生，还需要使用可靠性科学的方法对检测管理系统进行重新设计。这些方法首先要调查失败的系统原因，然后应用提高情景意识、闭环系统、改进交接、适时工作、停止解决问题的文化和实践、强制功能和简化、增强视觉提示以及谨慎使用信息技术和冗余等方法，同时避免次优化。新兴的检测管理系统和关键检测跟踪建议说明了如何应用这些原则可以增强患者安全的这一重要方面。
