Department of Surgery and Cancer, Imperial College, London, UK.
World J Surg. 2013 Apr;37(4):752-8. doi: 10.1007/s00268-013-1917-9.
Management of the acute trauma patient is complex, with potential for error and adverse events. Avoidable injuries and deaths are not well understood. Analysis of error incidence, type, and severity can aid in greater understanding of the root causes and guide future development of error reduction strategies.
Weekly case review meetings for a UK trauma center were retrospectively reviewed over 1 year. Errors were identified and corroborated with case-note review by a reviewer blinded to any identified events. All events were classified according to the Joint Commission on Accreditation of Healthcare Organisations taxonomy and were typified as structural or process errors and omission or commission errors.
A total of 1,752 major trauma patients were admitted over the study period, and 169 preventable errors were identified through analysis of case review meetings and case-note review. Clear patient harm was identified in 3.6 % of cases, with risk of harm in 30 %. Most errors occurred during the initial phase of care in the emergency department (51 %) and resulted most commonly in delays (56 %). The majority of errors were identified as process-related (88 %), with 62 % of them considered errors of omission.
This study reports error incidence in trauma and typifies them according to type and root cause. It identifies process errors and errors of omission in particular as the most common recurring events. Error theory suggests that protocols or checklists may most effectively address these errors. Further study should be prospective and may aid in the development of such interventions.
急性创伤患者的管理较为复杂，存在发生错误和不良事件的潜在风险。但目前人们对可避免的伤害和死亡事件并没有很好的了解。对错误发生率、类型和严重程度进行分析有助于更深入地了解根本原因，并为未来制定减少错误的策略提供指导。
对英国一家创伤中心的每周病例回顾会议进行了为期 1 年的回顾性分析。通过对病历进行审查，由一名对已识别事件不知情的审核员进行核实，从而确定错误。所有事件均根据联合委员会医疗组织分类法进行分类，并分为结构性或程序性错误以及遗漏或执行错误。
在研究期间共收治了 1752 例严重创伤患者，通过对病例回顾会议和病历审查的分析，共发现 169 例可预防的错误。有 3.6%的病例明确发生了患者伤害，有 30%的病例存在伤害风险。大多数错误发生在急诊科的初步治疗阶段（51%），最常见的后果是延误（56%）。大多数错误与流程相关（88%），其中 62%被认为是遗漏错误。
本研究报告了创伤中的错误发生率，并根据类型和根本原因对其进行了分类。研究特别确定了流程错误和遗漏错误是最常见的反复出现的错误。错误理论表明，使用协议或检查表可能是解决这些错误的最有效方法。进一步的研究应该是前瞻性的，这可能有助于此类干预措施的制定。
