Division of Emergency Medicine, Washington University School of Medicine, St. Louis, MO.
Department of Psychiatry, Washington University School of Medicine, St. Louis, MO.
Acad Emerg Med. 2019 Jun;26(6):670-679. doi: 10.1111/acem.13724. Epub 2019 Apr 24.
An adverse event (AE) is a physical harm experienced by a patient due to health care, requiring intervention. Describing and categorizing AEs is important for quality and safety assessment and identifying areas for improvement. Safety science suggests that improvement efforts should focus on preventing and mitigating harm rather than on error, which is commonplace but infrequently leads to AEs. Most taxonomies fail to describe harm experienced by patients (e.g., hypoxia, hemorrhage, anaphylaxis), focusing instead on errors, and use categorizations that are too broad to be useful (e.g., "communication error"). We set out to create a patient-centered, emergency department (ED)-specific framework for describing AEs and near misses to advance quality and safety in the acute care setting.
We performed a critical review of existing taxonomies of harm, evaluating their applicability to the ED. We identified and adopted a classification framework and developed a taxonomy using an iterative process categorizing approximately 600 previously identified AEs and near misses. We reviewed this taxonomy with collaborators at four medical centers, receiving feedback and providing clarification. We then disseminated a set of representative scenarios for these safety experts to categorize independently using the taxonomy. We calculated interrater reliability and performance compared to our criterion standard.
Our search identified candidate taxonomies for detailed review. We selected the Adventist Health Systems AE taxonomy and modified this for use in the ED, adopting a framework of categories, subcategories, and up to three modifiers to further describe events. On testing, overall reviewer agreement with the criterion standard was 92% at the category level and 88% at the subcategory level. Three of the four raters concurred in 55 of 59 scenarios (93%) and all four concurred in 46 of 59 scenarios (78%). At the subcategory level, there was complete agreement in 40 of 59 (68%) scenarios and majority agreement in 55 of 59 instances (93%). Performance of individual raters ranged from very good (88%, 52/59) to near perfect (98%, 58/59) at the main category level.
We developed a taxonomy of AEs and near misses for the ED, modified from an existing framework. Testing of the tool with minimal training yielded high performance and good inter-rater reliability. This taxonomy can be adapted and modified by EDs seeking to enhance their quality and safety reviews and characterize harm occurring in their EDs for quality improvement purposes.
不良事件（AE）是患者因医疗保健而遭受的身体伤害，需要干预。描述和分类 AE 对于质量和安全评估以及确定改进领域很重要。安全科学表明，改进工作应侧重于预防和减轻伤害，而不是错误，错误虽然很常见，但很少导致 AE。大多数分类法都未能描述患者所经历的伤害（例如，缺氧，出血，过敏反应），而是侧重于错误，并且使用的分类过于广泛而无法使用（例如，“沟通错误”）。我们着手创建一个以患者为中心的，专门针对急诊科（ED）的框架，以描述 AE 和未遂事件，从而在急性护理环境中提高质量和安全性。
我们对现有的伤害分类法进行了批判性评估，评估了其在急诊科的适用性。我们确定并采用了一种分类框架，并使用迭代过程对大约 600 个先前确定的 AE 和未遂事件进行了分类。我们与四个医疗中心的合作者一起审查了该分类法，并提供了反馈和澄清。然后，我们向这些安全专家分发了一组代表情况，供他们使用分类法进行独立分类。我们计算了组内相关系数，并与我们的标准进行了比较。
我们的搜索确定了候选分类法进行详细审查。我们选择了 Adventist Health Systems AE 分类法，并对其进行了修改，以在 ED 中使用，采用了类别，子类别和多达三个修饰符的框架来进一步描述事件。在测试中，整体审查者与标准的一致性在类别级别为 92％，在子类别级别为 88％。四名审查者中的三名在 55 个场景中的 59 个（93％）中达成一致，而所有四名审查者在 59 个场景中的 46 个（78％）中达成一致。在子类别级别，在 59 个场景中有 40 个（68％）达成完全一致，有 55 个（93％）达成多数一致。个别审查者的表现从非常好（88％，52/59）到接近完美（98％，58/59）。
我们从现有框架中修改了急诊科的 AE 和未遂事件分类法。经过最少的培训，该工具的测试性能很高，并且组内相关性很好。急诊科可以根据需要对该分类法进行修改和修改，以增强其质量和安全审查，并为质量改进目的描述在其急诊科发生的伤害。
