OʼConnell Karen J, Shaw Kathy N, Ruddy Richard M, Mahajan Prashant V, Lichenstein Richard, Olsen Cody S, Funai Tomohiko, Blumberg Stephen, Chamberlain James M
Pediatr Emerg Care. 2018 Apr;34(4):237-242. doi: 10.1097/PEC.0000000000001464.
Medical errors threaten patient safety, especially in the pediatric emergency department (ED) where overcrowding, multiple handoffs, and workflow interruptions are common. Errors related to process variance involve situations that are not consistent with standard ED operations or routine patient care.
SETTING/PARTICIPANTS: We performed a planned subanalysis of the Pediatric Emergency Care Applied Research Network incident reporting data classified as process variance events. Confidential deidentified incident reports (IRs) were collected and classified by 2 independent investigators. Events categorized as process variance were then subtyped for severity and contributing factors. Data were analyzed using descriptive statistics.
The study intention was to describe and measure reported medical errors related to process variance in 17 EDs in the Pediatric Emergency Care Applied Research Network from 2007 to 2008.
Between July 2007 and June 2008, 2906 eligible reports were reviewed. Process variance events were identified in 15.4% (447/2906). The majority were related to patient flow (35.4%), handoff communication (17.2%), and patient identification errors (15.9%). Most staff involved included nurses (47.9%) and physicians (28%); trainees were infrequently reported. The majority of events did not result in harm (65.7%); 17.9% (80/447) of cases were classified as unsafe conditions but did not reach the patient. Temporary harm requiring further treatment or hospitalization was reported in 5.6% (25/447). No events resulted in permanent harm, near death, or death. Contributing factors included human factors (92.1%), in particular handoff communication, interpersonal skills, and compliance with established procedures, and system-level errors (18.1%), including unclear or unavailable policies and inadequate staffing levels.
Although process variance events accounted for approximately 1 in 6 reported safety events, very few led to patient harm. Because human and system-level factors contributed to most of these events, our data provide an insight into potential areas for further investigation and improvements to mitigate errors in the ED setting.
医疗差错威胁患者安全，尤其是在儿科急诊科，那里过度拥挤、多次交接和工作流程中断很常见。与流程差异相关的差错涉及不符合急诊科标准操作或常规患者护理的情况。
设置/参与者：我们对儿科急诊护理应用研究网络事件报告数据进行了一项计划中的子分析，这些数据被归类为流程差异事件。由2名独立调查人员收集并分类保密的匿名事件报告（IR）。然后将归类为流程差异的事件按严重程度和促成因素进行子分类。使用描述性统计分析数据。
该研究的目的是描述和衡量2007年至2008年儿科急诊护理应用研究网络中17个急诊科报告的与流程差异相关的医疗差错。
在2007年7月至2008年6月期间，审查了2906份合格报告。在15.4%（447/2906）的报告中发现了流程差异事件。大多数与患者流程（35.4%）、交接沟通（17.2%）和患者身份识别错误（15.9%）有关。涉及的大多数工作人员包括护士（47.9%）和医生（28%）；很少报告实习人员。大多数事件未造成伤害（65.7%）；17.9%（80/447）的病例被归类为不安全状况，但未影响到患者。报告有5.6%（25/447）的病例造成了需要进一步治疗或住院的暂时伤害。没有事件导致永久性伤害、濒死或死亡。促成因素包括人为因素（92.1%），特别是交接沟通、人际交往能力和对既定程序的遵守情况，以及系统层面的差错（18.1%），包括政策不明确或不可用以及人员配备不足。
尽管流程差异事件约占报告的安全事件的六分之一，但很少导致患者受到伤害。由于人为和系统层面的因素导致了这些事件中的大多数，我们的数据为进一步调查和改进以减少急诊科差错的潜在领域提供了见解。
