Oremakinde Adetunji A, Bernstein Mark
Department of Neurological Surgery, University College Hospital, Ibadan, Nigeria;
J Neurosurg. 2014 Aug;121(2):297-304. doi: 10.3171/2014.5.JNS132341. Epub 2014 Jun 13.
Error recording and monitoring is an important component of error prevention and quality assurance in the health sector given the huge impact of medical errors on the well-being of patients and the financial loss incurred by health institutions. With this in mind, assessing the effect of reporting errors should be a cause worth pursuing. The object in this study was to examine the null hypothesis that recording and publishing errors do not affect error patterns in a clinical practice.
Intraoperative errors and their characteristics were prospectively recorded between May 2000 and May 2013 in the neurosurgical practice of the senior author (M.B.). The error pattern observed between May 2000 and August 2006, which has been previously described (Group A), was compared with the error pattern observed between September 2006 and May 2013 (Group B).
A total of 1108 cases in Group A and 974 cases in Group B were surgically treated. A total of 2684 errors were recorded in Group A, while 1892 errors were recorded in Group B. The ratios of cranial to spinal procedures performed in Groups A and B were 3:1 and 10:1, respectively, while the ratios of general to local anesthesia in the two groups were 2:1 and 1.3:1, respectively (p < 0.0001 for both). There was a significantly decreased proportion of cases with error (87% to 83%, p < 0.006), mean errors per case (2.4 to 1.9, p < 0.0001), proportion of error-related complications (16.7% to 5.5%, p < 0.002), and clinical impacts of error (2.7% to 1.0%, p < 0.0001) in Group B compared with Group A. Errors in Group B tended to be more preventable than those in Group A (85.8% vs 78.5%, p < 0.0001). A significant reduction was also noticed with most types of error. A descending trend in the mean errors per case was demonstrated from the years 2001 to 2012; however, an increased severity of errors (22.6% to 29.5%, p < 0.0001) was recorded in Group B compared with Group A.
Data in this study showed that the act of recording errors might alter behaviors, resulting in fewer errors.
鉴于医疗差错对患者健康的巨大影响以及医疗机构所遭受的经济损失，差错记录与监测是医疗卫生领域差错预防和质量保证的重要组成部分。有鉴于此，评估报告差错的效果应是一项值得追求的事业。本研究的目的是检验记录和公布差错不会影响临床实践中差错模式这一零假设。
2000年5月至2013年5月期间，对资深作者（M.B.）神经外科手术中的术中差错及其特征进行前瞻性记录。将2000年5月至2006年8月期间观察到的差错模式（A组）与2006年9月至2013年5月期间观察到的差错模式（B组）进行比较，A组差错模式此前已有描述。
A组共进行了1108例手术治疗，B组共进行了974例手术治疗。A组共记录了2684起差错，B组记录了1892起差错。A组和B组进行的颅脑手术与脊柱手术的比例分别为3:1和10:1，两组全身麻醉与局部麻醉的比例分别为2:1和1.3:1（两者p均<0.0001）。与A组相比，B组差错病例比例显著下降（从87%降至83%，p<0.006），每例平均差错数下降（从2.4降至1.9，p<0.0001），差错相关并发症比例下降（从16.7%降至5.5%，p<0.002），差错的临床影响下降（从2.7%降至1.0%，p<0.0001）。B组的差错比A组更易于预防（85.8%对78.5%，p<0.0001）。大多数类型的差错也有显著减少。2001年至2012年每例平均差错数呈下降趋势；然而，与A组相比，B组差错的严重程度有所增加（从22.6%增至29.5%，p<0.0001）。
本研究数据表明，记录差错的行为可能会改变行为，从而减少差错。
