Kosy Jonathan D, Kassam Al-Amin M, Hockings Michael
ST5 in Trauma and Orthopaedics, Torbay Hospital, Torquay.
Br J Hosp Med (Lond). 2013 Dec;74(12):691-3. doi: 10.12968/hmed.2013.74.12.691.
The authors set out to investigate the accuracy of the information their unit was inputting onto the National Joint Registry. This is important both in relation to implant surveillance and also to the use of these data to monitor the performance of surgeons.
A single consultant's arthroplasty patients were audited over 12 months. Data taken from the National Joint Registry were compared to the operation notes and the hospital's computer system.
Of 78 cases inputted, 27 (35%) were incorrect. Sixteen cases (21%) had the incorrect 'consultant in charge' recorded, eight cases (10%) had the incorrect 'operating surgeon' recorded and three cases (4%) had both errors. The most frequent inaccuracies resulted from listing by another consultant and incorrectly recorded trainee supervision. These errors were highlighted to the unit and a corrected process was designed. The intervention was to implement this process by presenting to the involved groups and displaying posters to prevent the error-producing process. The audit was repeated (after 6 months) showing eradication of the problem.
It is the surgeon's duty to ensure data recorded under his/her name are accurate and justify any discrepancies when compared to other surgeons. Pooling of patients and supervision of trainees are sources of potential error.
作者着手调查其科室录入国家关节注册系统信息的准确性。这对于植入物监测以及利用这些数据来监督外科医生的表现都很重要。
对一位顾问医生的关节置换手术患者进行了为期12个月的审核。将从国家关节注册系统获取的数据与手术记录和医院计算机系统进行比较。
在录入的78例病例中,27例(35%)存在错误。16例(21%)记录的“负责顾问医生”有误,8例(10%)记录的“主刀医生”有误,3例(4%)两者均有错误。最常见的不准确情况是由另一位顾问医生列出以及实习医生监督记录错误导致的。这些错误被反馈给科室,并设计了一个纠正流程。干预措施是通过向相关群体介绍并张贴海报来实施该流程,以防止产生错误的流程。(6个月后)重复审核显示问题已得到解决。
外科医生有责任确保以其名义记录的数据准确无误,并在与其他外科医生的数据进行比较时对任何差异做出解释。患者汇总和实习医生监督是潜在错误的来源。