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我们需要探讨一下误差:兽医实践中误差的成因及类型。

We need to talk about error: causes and types of error in veterinary practice.

作者信息

Oxtoby C, Ferguson E, White K, Mossop L

机构信息

School of Veterinary Medicine and Science, Nottingham University, Sutton Bonnington Campus, Leicestershire LE125RD, UK.

School of Psychology, Nottingham University, University Park, Nottingham NG7 2RD, UK.

出版信息

Vet Rec. 2015 Oct 31;177(17):438. doi: 10.1136/vr.103331. Epub 2015 Oct 20.

Abstract

Patient safety research in human medicine has identified the causes and common types of medical error and subsequently informed the development of interventions which mitigate harm, such as the WHO's safe surgery checklist. There is no such evidence available to the veterinary profession. This study therefore aims to identify the causes and types of errors in veterinary practice, and presents an evidence based system for their classification. Causes of error were identified from retrospective record review of 678 claims to the profession's leading indemnity insurer and nine focus groups (average N per group=8) with vets, nurses and support staff were performed using critical incident technique. Reason's (2000) Swiss cheese model of error was used to inform the interpretation of the data. Types of error were extracted from 2978 claims records reported between the years 2009 and 2013. The major classes of error causation were identified with mistakes involving surgery the most common type of error. The results were triangulated with findings from the medical literature and highlight the importance of cognitive limitations, deficiencies in non-technical skills and a systems approach to veterinary error.

摘要

人类医学领域的患者安全研究已确定了医疗差错的原因和常见类型,并据此推动了旨在减轻伤害的干预措施的发展,例如世界卫生组织的安全手术清单。兽医行业则没有此类证据。因此,本研究旨在确定兽医实践中差错的原因和类型,并提出一个基于证据的差错分类系统。通过对该行业主要赔偿保险公司收到的678份索赔申请进行回顾性记录审查来确定差错原因,并采用关键事件技术对9个由兽医、护士和辅助人员组成的焦点小组(每组平均人数=8)进行了调查。利用瑞森(2000年)的差错瑞士奶酪模型来指导对数据的解读。差错类型从2009年至2013年期间报告的2978份索赔记录中提取。差错原因的主要类别已确定,涉及手术的失误是最常见的差错类型。研究结果与医学文献中的发现相互印证,突出了认知局限、非技术技能缺陷以及采用系统方法应对兽医差错的重要性。

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