Department of Surgery, College of Human Medicine, Michigan State University, Lansing, Michigan 48912, USA.
J Surg Res. 2012 Sep;177(1):43-8. doi: 10.1016/j.jss.2012.05.007. Epub 2012 Jun 5.
Performance improvement driven by the review of surgical morbidity and mortality is often limited to critiques of individual cases with a focus on individual errors. Little attention has been given to an analysis of why a decision seemed right at the time or to lower-level root causes. The application of scientific performance improvement has the potential to bring to light deeper levels of understanding of surgical decision-making, care processes, and physician psychology.
A comprehensive retrospective chart review of previously discussed morbidity and mortality cases was performed with an attempt to identify areas where we could better understand or influence behavior or systems. We avoided focusing on traditional sources of human error such as lapses of vigilance or memory. An iterative process was used to refine the practical areas for possible intervention. Definitions were then created for the major categories and subcategories.
Of a sample of 152 presented cases, the root cause for 96 (63%) patient-related events was identified as uni-factorial in origin, with 51 (34%) cases strictly related to patient disease with no other contributing causes. Fifty-six cases (37%) had multiple causes. The remaining 101 cases (66%) were categorized into two areas where the ability to influence outcomes appeared possible. Technical issues were found in 27 (18%) of these cases and 74 (74%) were related to disorganized care problems. Of the 74 cases identified with disorganized care, 42 (42%) were related to failures in critical thinking, 18 (18%) to undisciplined treatment strategies, 8 (8%) to structural failures, and 6 (6%) were related to failures in situational awareness.
On a comprehensive review of cases presented at the morbidity and mortality conference, disorganized care played a large role in the cases presented and may have implications for future curriculum changes. The failure to think critically, to deliver disciplined treatment strategies, to recognize structural failures, and to achieve situational awareness contributed to the morbidities and mortalities. Future research may determine if focused training in these areas improves patient outcomes.
通过审查手术发病率和死亡率来推动绩效改进的做法通常仅限于对个别病例的批评，重点关注个别错误。很少有人关注为什么当时的决策看起来是正确的，或者关注更低层次的根本原因。科学绩效改进的应用有可能使我们更深入地了解手术决策、护理过程和医生心理。
对之前讨论过的发病率和死亡率病例进行了全面的回顾性图表审查，试图确定我们可以更好地理解或影响行为或系统的领域。我们避免将重点放在警觉性或记忆力等传统的人为错误来源上。采用迭代过程来完善可能进行干预的实际领域。然后为主要类别和子类别创建定义。
在 152 例提出的病例中，96 例（63%）与患者相关的事件的根本原因被确定为单一因素起源，其中 51 例（34%）病例与患者疾病严格相关，没有其他致病原因。56 例（37%）有多个原因。其余 101 例（66%）分为两个领域，在这两个领域中，影响结果的能力似乎是可能的。在这些病例中，发现 27 例（18%）存在技术问题，其中 74 例（74%）与护理混乱问题有关。在确定与护理混乱有关的 74 例病例中，42 例（42%）与批判性思维失败有关，18 例（18%）与无纪律治疗策略有关，8 例（8%）与结构性失败有关，6 例（6%）与情境意识失败有关。
在对发病率和死亡率会议上提出的病例进行全面审查后发现，护理混乱在提出的病例中起了很大作用，可能对未来的课程改革产生影响。未能进行批判性思维、实施纪律性治疗策略、认识结构性失败以及实现情境意识导致了发病率和死亡率的发生。未来的研究可能会确定在这些领域进行有针对性的培训是否会改善患者的结果。
