Nathwani Jay N, Fiers Rebekah M, Ray Rebecca D, Witt Anna K, Law Katherine E, DiMarco ShannonM, Pugh Carla M
Division of General Surgery, University of Wisconsin, Madison, Wisconsin.
Department of Industrial and Systems Engineering, University of Wisconsin, Madison, Wisconsin.
J Surg Educ. 2016 Nov-Dec;73(6):e84-e90. doi: 10.1016/j.jsurg.2016.08.004. Epub 2016 Sep 23.
The purpose of this study is to coevaluate resident technical errors and decision-making capabilities during placement of a subclavian central venous catheter (CVC). We hypothesize that there would be significant correlations between scenario-based decision-making skills and technical proficiency in central line insertion. We also predict residents would face problems in anticipating common difficulties and generating solutions associated with line placement.
Participants were asked to insert a subclavian central line on a simulator. After completion, residents were presented with a real-life patient photograph depicting CVC placement and asked to anticipate difficulties and generate solutions. Error rates were analyzed using chi-square tests and a 5% expected error rate. Correlations were sought by comparing technical errors and scenario-based decision-making skills.
This study was performed at 7 tertiary care centers.
Study participants (N = 46) largely consisted of first-year research residents who could be followed longitudinally. Second-year research and clinical residents were not excluded.
In total, 6 checklist errors were committed more often than anticipated. Residents committed an average of 1.9 errors, significantly more than the 1 error, at most, per person expected (t(44) = 3.82, p < 0.001). The most common error was performance of the procedure steps in the wrong order (28.5%, p < 0.001). Some of the residents (24%) had no errors, 30% committed 1 error, and 46 % committed more than 1 error. The number of technical errors committed negatively correlated with the total number of commonly identified difficulties and generated solutions (r (33) = -0.429, p = 0.021, r (33) = -0.383, p = 0.044, respectively).
Almost half of the surgical residents committed multiple errors while performing subclavian CVC placement. The correlation between technical errors and decision-making skills suggests a critical need to train residents in both technique and error management.
本研究旨在共同评估住院医师在锁骨下中心静脉导管(CVC)置入过程中的技术错误和决策能力。我们假设基于情景的决策技能与中心静脉置管技术熟练程度之间存在显著相关性。我们还预测住院医师在预见常见困难和提出与置管相关的解决方案方面会面临问题。
要求参与者在模拟器上插入锁骨下中心静脉导管。完成后,向住院医师展示一张描绘CVC置管的真实患者照片,并要求他们预见困难并提出解决方案。使用卡方检验和5%的预期错误率分析错误率。通过比较技术错误和基于情景的决策技能来寻求相关性。
本研究在7个三级医疗中心进行。
研究参与者(N = 46)主要由可以进行纵向跟踪的一年级住院医师组成。二年级研究型和临床型住院医师也未被排除。
总共出现了6项清单错误,其出现频率高于预期。住院医师平均犯1.9个错误,明显多于每人最多预期的1个错误(t(44) = 3.82,p < 0.001)。最常见的错误是程序步骤执行顺序错误(28.5%,p < 0.001)。一些住院医师(24%)没有错误,30%犯了1个错误,46%犯了不止1个错误。所犯技术错误的数量与常见识别困难和提出的解决方案的总数呈负相关(分别为r(33) = -0.429,p = 0.021;r(33) = -0.383,p = 0.044)。
几乎一半的外科住院医师在进行锁骨下CVC置管时犯了多个错误。技术错误与决策技能之间的相关性表明迫切需要对住院医师进行技术和错误管理方面的培训。