Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.
Department of Medicine, Baylor College of Medicine, Houston, Texas.
JAMA Netw Open. 2019 Jul 3;2(7):e198067. doi: 10.1001/jamanetworkopen.2019.8067.
Potentially preventable adverse events remain a formidable cause of patient harm and health care expenditure despite advances in systems-based risk-reduction strategies.
To analyze and describe the incidence of human performance deficiencies (HPDs) during the provision of surgical care to identify opportunities to enhance patient safety.
DESIGN, SETTING, AND PARTICIPANTS: This quality improvement study used a new taxonomy to inform the development and implementation of an HPD classifier tool to categorize HPDs into errors associated with cognitive, technical, and team dynamic functions. The HPD classifier tool was then used to concurrently analyze surgical adverse events in 3 adult hospital affiliates-a level I municipal trauma center, a quaternary care university hospital, and a US Veterans Administration hospital-from January 2, 2018, to June 30, 2018. Surgical trainees presented data describing all adverse events associated with surgical services at weekly hospital-based morbidity and mortality conferences. Adverse events and HPDs were classified in discussion with attending faculty and residents. Data were analyzed from July 9, 2018, to December 23, 2018.
The incidence and primary and secondary causes of HPDs were classified using an HPD classifier tool.
A total of 188 adverse events were recorded, including 182 adverse events (96.8%) among 5365 patients who underwent surgical operations and 6 adverse events (3.2%) among patients undergoing nonoperative treatment. Among these 188 adverse events, 106 (56.4%) were associated with HPDs. Among these 106 HPD adverse events, a total of 192 HPDs (mean [SD], 1.8 [0.9] HPDs per HPD event) were identified. Human performance deficiencies were categorized as execution (98 HPDs [51.0%]), planning or problem solving (55 HPDs [28.6%]), communication (24 HPDs [12.5%]), teamwork (9 HPDs [4.7%]), and rules violation (6 HPDs [3.1%]). Human performance deficiencies most commonly presented as cognitive errors in execution of care or in case planning or problem solving (99 of 192 HPDs [51.6%]). In contrast, technical execution errors without other associated HPDs were observed in 20 of 192 HPDs (10.4%).
Human performance deficiencies were identified in more than half of adverse events, most commonly associated with cognitive error in the execution of care. These data provide a framework and impetus for new quality improvement initiatives incorporating cognitive training to mitigate human error in surgery.
尽管在基于系统的降低风险策略方面取得了进展，但潜在可预防的不良事件仍然是造成患者伤害和医疗支出的一个严重原因。
分析和描述手术护理过程中人为绩效缺陷（HPD）的发生率，以确定增强患者安全性的机会。
设计、设置和参与者：本质量改进研究使用了一种新的分类法来制定和实施 HPD 分类器工具，以将 HPD 归类为与认知、技术和团队动态功能相关的错误。然后，使用 HPD 分类器工具同时分析 2018 年 1 月 2 日至 6 月 30 日期间 3 家成人医院分院（一家 I 级市创伤中心、一家四级护理大学医院和一家美国退伍军人管理局医院）的外科不良事件。外科受训人员每周在医院举办的发病率和死亡率会议上介绍与外科服务相关的所有不良事件的数据。在与主治医生和住院医师的讨论中对不良事件和 HPD 进行分类。数据于 2018 年 7 月 9 日至 12 月 23 日进行分析。
使用 HPD 分类器工具对 HPD 的发生率和主要及次要原因进行分类。
共记录了 188 起不良事件，其中 5365 名接受手术的患者中有 182 起（96.8%）不良事件和 6 名接受非手术治疗的患者中有 6 起（3.2%）不良事件。在这 188 起不良事件中，有 106 起（56.4%）与 HPD 有关。在这 106 起 HPD 不良事件中，共发现 192 起 HPD（平均[SD]每起 HPD 事件 1.8[0.9]起 HPD）。人为绩效缺陷分为执行（98 起 HPD[51.0%]）、计划或解决问题（55 起 HPD[28.6%]）、沟通（24 起 HPD[12.5%]）、团队合作（9 起 HPD[4.7%]）和违反规则（6 起 HPD[3.1%]）。人为绩效缺陷最常见的表现为护理执行或病例计划或解决问题中的认知错误（192 起 HPD 中的 99 起[51.6%]）。相比之下，在 192 起 HPD 中观察到了 20 起没有其他相关 HPD 的技术执行错误（10.4%）。
在超过一半的不良事件中发现了人为绩效缺陷，最常见的是与护理执行中的认知错误有关。这些数据为新的质量改进计划提供了框架和动力，该计划纳入认知训练以减轻手术中的人为错误。
