手术诊断错误的特征和促成因素：对加拿大封闭医疗法律案件和投诉的分析。
Characteristics and contributing factors of diagnostic error in surgery: analysis of closed medico-legal cases and complaints in Canada.
机构信息
From the Department of Medicine, Sinai Health and University of Toronto, Toronto, Ont. (Kwan); Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, Ont. (Calder, Bowman, MacIntyre, Mimeault, Honey, Dunn, Garber); the Department of Emergency Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Calder); the Canadian Association of General Surgeons, Kanata, Ont. (Mimeault); the Department of Obstetrics and Gynecology, Queensway Carleton Hospital, Ottawa, Ont. (Honey); the Department of Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Garber); Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center (Singh); and Baylor College of Medicine, Houston, TX, USA (Singh).
出版信息
Can J Surg. 2024 Feb 6;67(1):E58-E65. doi: 10.1503/cjs.003523. Print 2024 Jan-Feb.
BACKGROUND
Diagnostic errors lead to patient harm; however, most research has been conducted in nonsurgical disciplines. We sought to characterize diagnostic error in the pre-, intra-, and postoperative surgical phases, describe their contributing factors, and quantify their impact related to patient harm.
METHODS
We performed a retrospective analysis of closed medico-legal cases and complaints using a database representing more than 95% of all Canadian physicians. We included cases if they involved a legal action or complaint that closed between 2014 and 2018 and involved a diagnostic error assigned by peer expert review to a surgeon.
RESULTS
We identified 387 surgical cases that involved a diagnostic error. The surgical specialties most often associated with diagnostic error were general surgery ( = 151, 39.0%), gynecology ( = 71, 18.3%), and orthopedic surgery ( = 48, 12.4%), but most surgical specialties were represented. Errors occurred more often in the postoperative phase ( = 171, 44.2%) than in the pre- ( = 127, 32.8%) or intra-operative ( = 120, 31.0%) phases of surgical care. More than 80% of the contributing factors for diagnostic errors were related to providers, with clinical decision-making being the principal contributing factor. Half of the contributing factors were related to the health care team ( = 194, 50.1%), the most common of which was communication breakdown. More than half of patients involved in a surgical diagnostic error experienced at least moderate harm, with 1 in 7 cases resulting in death.
CONCLUSION
In our cohort, diagnostic errors occurred in most surgical disciplines and across all surgical phases of care; contributing factors were commonly attributed to provider clinical decision-making and communication breakdown. Surgical patient safety efforts should include diagnostic errors with a focus on understanding and reducing errors in surgical clinical decision-making and improving communication.
背景
诊断错误会导致患者受到伤害；然而，大多数研究都集中在非外科领域。我们试图描述手术前、手术中和手术后阶段的诊断错误，描述其促成因素，并量化与患者伤害相关的影响。
方法
我们使用代表超过 95%的加拿大医生的数据库，对已结案的医学法律案例和投诉进行回顾性分析。如果案例涉及法律诉讼或投诉，且由同行专家审查归因于外科医生的诊断错误，并在 2014 年至 2018 年期间结案，则将其纳入研究。
结果
我们确定了 387 例涉及诊断错误的手术案例。最常与诊断错误相关的外科专业是普通外科（= 151，39.0%）、妇科（= 71，18.3%）和骨科（= 48，12.4%），但大多数外科专业都有涉及。错误更常发生在手术后期（= 171，44.2%），而不是手术前期（= 127，32.8%）或手术期（= 120，31.0%）。导致诊断错误的促成因素中，超过 80%与医务人员有关，临床决策是主要的促成因素。有一半的促成因素与医疗团队有关（= 194，50.1%），其中最常见的是沟通中断。涉及外科诊断错误的患者中，超过一半至少经历了中度伤害，每 7 例中就有 1 例导致死亡。
结论
在我们的队列中，诊断错误发生在大多数外科专业和所有手术护理阶段；促成因素通常归因于医务人员的临床决策和沟通中断。外科患者安全工作应包括诊断错误，并侧重于了解和减少外科临床决策中的错误，以及改善沟通。
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