创伤护理中的错误减少：来自匿名、全国性、多中心死亡率报告系统的经验教训。
Error reduction in trauma care: Lessons from an anonymized, national, multicenter mortality reporting system.
机构信息
From the Department of Surgery (D.M.H., M.P.G., P.W., A.B.N.), Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada; Department of Surgery (S.P.M.), UT Southwestern Medical Center, Dallas, Texas; Department of Surgery (R.M.S.), University of Texas Health Science Center, San Antonio, Texas; Trauma Quality Improvement Program (B.P., A.T., A.B.N.), American College of Surgeons, Chicago, Illinois; Feinberg School of Medicine (A.T.), Northwestern University, Chicago, Illinois; Department of Anesthesia (A.J.), Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada; and Division of Trauma, Critical Care and Burn Surgery (E.M.B.), University of Washington, Seattle, Washington.
出版信息
J Trauma Acute Care Surg. 2022 Mar 1;92(3):473-480. doi: 10.1097/TA.0000000000003485.
BACKGROUND
Twenty years ago, the landmark report To Err Is Human illustrated the importance of system-level solutions, in contrast to person-level interventions, to assure patient safety. Nevertheless, rates of preventable deaths, particularly in trauma care, have not materially changed. The American College of Surgeons Trauma Quality Improvement Program developed a voluntary Mortality Reporting System to better understand the underlying causes of preventable trauma deaths and the strategies used by centers to prevent future deaths. The objective of this work is to describe the factors contributing to potentially preventable deaths after injury and to evaluate the effectiveness of strategies identified by trauma centers to mitigate future harm, as reported in the Mortality Reporting System.
METHODS
An anonymous structured web-based reporting template based on the Joint Commission on Accreditation of Healthcare Organizations taxonomy was made available to trauma centers participating in the Trauma Quality Improvement Program to allow for reporting of deaths that were potentially preventable. Contributing factors leading to death were evaluated. The effectiveness of mitigating strategies was assessed using a validated framework and mapped to tiers of effectiveness ranging from person-focused to system-oriented interventions.
RESULTS
Over a 2-year period, 395 deaths were reviewed. Of the mortalities, 33.7% were unanticipated. Errors pertained to management (50.9%), clinical performance (54.7%), and communication (56.2%). Human failures were cited in 61% of cases. Person-focused strategies like education were common (56.0%), while more effective system-based strategies were seldom used. In 7.3% of cases, centers could not identify a specific strategy to prevent future harm.
CONCLUSION
Most strategies to reduce errors in trauma centers focus on changing the performance of providers rather than system-level interventions such as automation, standardization, and fail-safe approaches. Centers require additional support to develop more effective mitigations that will prevent recurrent errors and patient harm.
LEVEL OF EVIDENCE
Therapeutic/Care Management, level V.
背景
二十年前，具有里程碑意义的报告《人非圣贤，孰能无过》阐明了系统层面解决方案的重要性，与人员层面干预措施相比，系统层面解决方案更能确保患者安全。然而，可预防的死亡人数，特别是在创伤护理方面，并没有实质性的改变。美国外科医师学会创伤质量改进计划开发了一个自愿性死亡率报告系统，以更好地了解可预防创伤死亡的根本原因以及各中心用来预防未来死亡的策略。这项工作的目的是描述导致受伤后潜在可预防死亡的因素，并评估创伤中心报告的死亡率报告系统中确定的减轻未来伤害的策略的有效性。
方法
为参与创伤质量改进计划的创伤中心提供了一个基于联合委员会医疗机构认证组织分类法的匿名结构化网络报告模板，以便报告潜在可预防的死亡病例。评估导致死亡的促成因素。使用经过验证的框架评估减轻策略的有效性，并将其映射到从以人为中心到以系统为导向的干预措施的有效性分层。
结果
在两年的时间里，共审查了 395 例死亡病例。在这些死亡病例中，33.7%是意料之外的。导致死亡的错误涉及管理（50.9%）、临床表现（54.7%）和沟通（56.2%）。在 61%的情况下，都提到了人为失误。像教育这样的以人为中心的策略很常见（56.0%），而更有效的系统层面策略很少使用。在 7.3%的情况下，中心无法确定防止未来伤害的具体策略。
结论
大多数减少创伤中心错误的策略都侧重于改变提供者的表现，而不是系统层面的干预措施，如自动化、标准化和故障安全方法。中心需要额外的支持来制定更有效的缓解措施，以防止再次发生错误和患者伤害。
证据水平
治疗/护理管理，五级。
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