Sari A Akbari, Doshmangir L, Sheldon T
Dept. of Health Management and Economics, and Centre of Knowledge Translation and Exchange, Tehran University of Medical Science, Iran.
Iran J Public Health. 2010;39(3):1-15. Epub 2010 Sep 30.
Understanding the nature and causes of medical adverse events may help their prevention. This systematic review explores the types, risk factors, and likely causes of preventable adverse events in the hospital sector.
MEDLINE (1970-2008), EMBASE, CINAHL (1970-2005) and the reference lists were used to identify the studies and a structured narrative method used to synthesise the data.
Operative adverse events were more common but less preventable and diagnostic adverse events less common but more preventable than other adverse events. Preventable adverse events were often associated with more than one contributory factor. The majority of adverse events were linked to individual human error, and a significant proportion of these caused serious patient harm. Equipment failure was involved in a small proportion of adverse events and rarely caused patient harm. The proportion of system failures varied widely ranging from 3% to 85% depending on the data collection and classification methods used.
Operative adverse events are more common but less preventable than diagnostic adverse events. Adverse events are usually associated with more than one contributory factor, the majority are linked to individual human error, and a proportion of these with system failure.
了解医疗不良事件的性质和原因可能有助于预防这些事件。本系统评价探讨了医院部门可预防不良事件的类型、风险因素及可能原因。
利用MEDLINE（1970 - 2008年）、EMBASE、CINAHL（1970 - 2005年）及参考文献列表来识别研究，并采用结构化叙述方法对数据进行综合分析。
与其他不良事件相比，手术不良事件更为常见，但可预防性较低；诊断不良事件虽不常见，但可预防性较高。可预防的不良事件往往与不止一个促成因素相关。大多数不良事件与个人人为失误有关，其中很大一部分对患者造成了严重伤害。设备故障在不良事件中所占比例较小，很少导致患者伤害。系统故障所占比例差异很大，介于3%至85%之间，具体取决于所采用的数据收集和分类方法。
手术不良事件比诊断不良事件更为常见，但可预防性更低。不良事件通常与不止一个促成因素相关，大多数与个人人为失误有关，其中一部分与系统故障有关。
