Ricci Michael A, Brumsted John R
Fletcher Allen Health Care, Burlington, VT, USA.
Aviat Space Environ Med. 2012 Apr;83(4):441-4. doi: 10.3357/asem.3149.2012.
Since the publication of the Institute of Medicine report estimating nearly 100,000 deaths per year from medical errors, hospitals and physicians have a renewed focus upon error reduction. We implemented a surgical crew resource management (CRM) program for all operating room (OR) personnel.
In our academic medical center, 19,000 procedures per year are performed in 27 operating rooms. Mandatory CRM training was implemented for all peri-operative personnel. Aviation techniques introduced included a pre-operative checklist and brief, post-operative debrief, read and initial files, and various other aviation-based techniques. Compliance with conduct of the brief/debrief was monitored as well as wrong-site surgeries and retained foreign body events. The malpractice insurance database for claims was also queried for the period prior to and after training.
Initial training was accomplished for 517 people, including all anesthesiologists, surgeons, nurses, technicians, and OR assistants. Pre-operative briefing increased from 6.7 to 99% within 4 mo. Wrong site surgeries and retained foreign bodies decreased from a high of seven in 2007 to none in 2008, but, after 14 mo without additional training, these rose to five in 2009. Malpractice expenses (payouts and legal fees) totaled $793,000 (2003-2007), but have been zero since 2008.
CRM training and implementation had an impact on reducing the incidence of wrong site surgery and retained foreign bodies in our operating rooms. However, constant reinforcement and refresher training is necessary for sustained results. Though no one technique can prevent all errors, CRM can effect culture change, producing a safer environment.
自医学研究所发布报告估计每年因医疗差错导致近10万例死亡以来，医院和医生重新将重点放在减少差错上。我们为所有手术室人员实施了一项手术团队资源管理（CRM）计划。
在我们的学术医疗中心，27个手术室每年进行19000例手术。对所有围手术期人员实施了强制性的CRM培训。引入的航空技术包括术前检查表和简报、术后汇报、阅读并签署文件以及各种其他基于航空领域的技术。对简报/汇报的执行情况以及手术部位错误和异物残留事件进行了监测。还查询了培训前后期间的医疗事故保险索赔数据库。
517人完成了初始培训，包括所有麻醉医生、外科医生、护士、技术人员和手术室助理。术前简报在4个月内从6.7%增加到99%。手术部位错误和异物残留从2007年的最高7例降至2008年的零例，但在没有额外培训的14个月后，2009年又升至5例。医疗事故费用（赔付和法律费用）在2003 - 2007年总计79.3万美元，但自2008年以来一直为零。
CRM培训和实施对降低我们手术室手术部位错误和异物残留的发生率产生了影响。然而，为了保持持续的效果，持续强化和复习培训是必要的。虽然没有一种技术可以预防所有差错，但CRM可以影响文化变革，营造一个更安全的环境。
