Neily Julia, Mills Peter D, Paull Douglas E, Mazzia Lisa M, Turner James R, Hemphill Robin R, Gunnar William
Veterans Health Administration, White River Junction, Vermont, USA.
Am Surg. 2012 Nov;78(11):1276-80.
The purpose of this report is to discuss surgical adverse event lessons learned and to recommend action. Examples of incorrect surgical adverse events managed in the Veterans Health Administration (VHA) patient safety system and results of a survey regarding the impact of the surgery lessons learned process are provided. The VHA implemented a process for sharing deidentified stories of surgical lessons learned. The cases are in-operating room selected examples from lessons learned from October 1, 2009, to June 30, 2011. Examples selected illustrate helpful human factors principles. To learn more about the awareness and impact of the lessons learned, we conducted a survey with Chiefs of Surgery in the VHA. The types of examples of adverse events include wrong eye implants, incorrect nerve blocks, and wrong site excisions of lesions. These are accompanied by human factors recommendations and change concepts such as designing the system to prevent mistakes, using differentiation, minimizing handoffs, and standardizing how information is communicated. The survey response rate was 76 per cent (88 of 132). Of those who had seen the surgical lessons learned (76% [67 of 88]), the majority (87%) reported they were valuable and 85% that they changed or reinforced patient safety behaviors in their facility as a result of surgical lessons learned. Simply having a policy will not ensure patient safety. When reviewing adverse events, human factors must be considered as a cause for error and for the failure to follow policy without assigning blame. VHA surgeons reported that the surgery lessons learned were valuable and impacted practice.
本报告的目的是讨论从手术不良事件中吸取的经验教训并提出行动建议。文中提供了在退伍军人健康管理局（VHA）患者安全系统中处理的不当手术不良事件案例，以及一项关于手术经验教训吸取过程影响的调查结果。VHA实施了一个分享已去除身份信息的手术经验教训故事的流程。这些案例是从2009年10月1日至2011年6月30日期间吸取的经验教训中选取的手术室实例。所选案例阐述了有益的人为因素原则。为了更多地了解经验教训的知晓情况和影响，我们对VHA的外科主任进行了一项调查。不良事件的示例类型包括错误的眼部植入、不正确的神经阻滞以及病变部位的错误切除。这些案例还伴有关于人为因素的建议和变革理念，例如设计系统以防止错误、采用区分方法、尽量减少交接以及规范信息传达方式。调查回复率为76%（132人中的88人）。在那些看过手术经验教训的人中（76%[88人中的67人]），大多数（87%）报告称这些经验教训很有价值，85%的人表示由于手术经验教训，他们所在机构的患者安全行为得到了改变或强化。仅仅制定一项政策并不能确保患者安全。在审查不良事件时，必须将人为因素视为错误的原因以及未能遵守政策的原因，而不进行指责。VHA的外科医生报告称，手术经验教训很有价值且影响了实践。
