Hickey Edward, Pham-Hung Eric, Nosikova Yaroslavna, Halvorsen Fredrik, Gritti Michael, Schwartz Steven, Caldarone Christopher A, Van Arsdell Glen
Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada.
Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada.
Ann Thorac Surg. 2017 Apr;103(4):1300-1307. doi: 10.1016/j.athoracsur.2016.08.075. Epub 2016 Dec 9.
We introduced the National Aeronautics and Space Association threat-and-error model to our surgical unit. All admissions are considered flights, which should pass through stepwise deescalations in risk during surgical recovery. We hypothesized that errors significantly influence risk deescalation and contribute to poor outcomes.
Patient flights (524) were tracked in real time for threats, errors, and unintended states by full-time performance personnel. Expected risk deescalation was wean from mechanical support, sternal closure, extubation, intensive care unit (ICU) discharge, and discharge home. Data were accrued from clinical charts, bedside data, reporting mechanisms, and staff interviews. Infographics of flights were openly discussed weekly for consensus.
In 12% (64 of 524) of flights, the child failed to deescalate sequentially through expected risk levels; unintended increments instead occurred. Failed deescalations were highly associated with errors (426; 257 flights; p < 0.0001). Consequential errors (263; 173 flights) were associated with a 29% rate of failed deescalation versus 4% in flights with no consequential error (p < 0.0001). The most dangerous errors were apical errors typically (84%) occurring in the operating room, which caused chains of propagating unintended states (n = 110): these had a 43% (47 of 110) rate of failed deescalation (versus 4%; p < 0.0001). Chains of unintended state were often (46%) amplified by additional (up to 7) errors in the ICU that would worsen clinical deviation. Overall, failed deescalations in risk were extremely closely linked to brain injury (n = 13; p < 0.0001) or death (n = 7; p < 0.0001).
Deaths and brain injury after pediatric cardiac surgery almost always occur from propagating error chains that originate in the operating room and are often amplified by additional ICU errors.
我们将美国国家航空航天局的威胁与差错模型引入了我们的外科病房。所有入院病例都被视为飞行任务，在手术恢复过程中应逐步降低风险。我们假设差错会显著影响风险降级，并导致不良后果。
由专职绩效人员实时跟踪524例患者飞行任务中的威胁、差错和意外状况。预期的风险降级包括撤离机械支持、关闭胸骨、拔管、重症监护病房（ICU）出院和出院回家。数据来自临床病历、床边数据、报告机制和工作人员访谈。每周都会公开讨论飞行任务的信息图表以达成共识。
在12%（524例中的64例）的飞行任务中，患儿未能按预期风险水平依次降级；相反出现了意外的风险增加。风险降级失败与差错高度相关（426次；257例飞行任务；p<0.0001）。后果性差错（263次；173例飞行任务）与29%的风险降级失败率相关，而无后果性差错的飞行任务中这一比例为4%（p<0.0001）。最危险的差错通常是顶端差错（84%），发生在手术室，会导致一系列意外状况的连锁反应（n=110）：这些差错导致风险降级失败的比例为43%（110例中的47例）（相比之下为4%；p<0.0001）。意外状况的连锁反应在ICU中常（46%）因额外（多达7次）的差错而扩大，这会使临床偏差恶化。总体而言，风险降级失败与脑损伤（n=13；p<0.0001）或死亡（n=7；p<0.0001）密切相关。
小儿心脏手术后的死亡和脑损伤几乎总是由源自手术室的差错连锁反应引起，且常因ICU中的额外差错而扩大。
