Department of Forensic Medicine, Wroclaw Medical University, Wroclaw, Poland.
Med Princ Pract. 2015;24(2):159-64. doi: 10.1159/000369463. Epub 2014 Dec 10.
To investigate the adverse events and potential risk factors in patients who develop sepsis.
Fifty-five medico-legal opinion forms relating to sepsis cases issued by the Department of Forensic Medicine, Wroclaw, Poland, between 2004 and 2013 were analyzed for medical errors and risk factors for adverse events.
The most common causes of medical errors were a lack of knowledge in recognition, diagnosis and therapy as well as ignorance of risk. The common risk factors for adverse events were deferral of a diagnostic or therapeutic decision, high-level anxiety of patients or their families about the patient's health and actively seeking for help. The most significant risk factors were communication errors, not enough medical staff, stereotype-based thinking about diseases and providing easy explanations for serious symptoms.
The most common cause of adverse events related to sepsis in the Polish health-care system was a lack of knowledge about the symptoms, diagnosis and treatment as well as the ignoring of danger. A possible means of improving safety might be through spreading knowledge and creating medical management algorithms for all health-care workers, especially physicians.
调查发生脓毒症患者的不良事件和潜在风险因素。
分析了波兰弗罗茨瓦夫法医学系 2004 年至 2013 年间出具的 55 份与脓毒症病例有关的医学鉴定意见表，以确定医疗错误和不良事件的风险因素。
最常见的医疗错误原因是缺乏识别、诊断和治疗方面的知识，以及对风险的忽视。不良事件的常见风险因素包括诊断或治疗决策的延迟、患者或其家属对患者健康的高度焦虑以及积极寻求帮助。最显著的风险因素是沟通错误、医护人员不足、对疾病的刻板思维以及对严重症状的简单解释。
波兰医疗体系中与脓毒症相关的不良事件的最常见原因是对症状、诊断和治疗的知识不足以及对危险的忽视。通过传播知识和为所有医护人员，特别是医生制定医疗管理算法，可能是提高安全性的一种手段。
