Couch N P, Tilney N L, Rayner A A, Moore F D
N Engl J Med. 1981 Mar 12;304(11):634-7. doi: 10.1056/NEJM198103123041103.
We conducted a one-year prospective survey to identify adverse outcomes due to error during care in the field of general surgery. We identified 36 such cases among 5612 surgical admissions to the Peter Bent Brigham Hospital, but in 23 cases the initiating mishap had occurred in another hospital before transfer. In two thirds of the cases the mishap was due to an error of commission: an unnecessary, defective or inappropriate operative procedure. Twenty of these patients died in the hospital, and in 11 death was directly attributable to the error. Five of the 16 survivors left the hospital with serious physical impairment. A satisfactory outcome was achieved in only 11 cases (31%). The average hospital stay was 42 days, with the duration ranging from one to 325 days; the total cost for the 36 patients was $1,732,432. We suggest that all hospitals develop comprehensive methods to identify and prevent these costly and unnecessary events.
我们进行了一项为期一年的前瞻性调查，以确定普通外科护理过程中因失误导致的不良后果。在彼得·本特·布里格姆医院收治的5612例外科患者中，我们识别出36例此类病例，但其中23例引发事故在转院之前已在其他医院发生。在三分之二的病例中，事故是由于操作失误：不必要的、有缺陷的或不适当的手术程序。这些患者中有20例在医院死亡，其中11例死亡直接归因于失误。16名幸存者中有5人出院时伴有严重身体损伤。只有11例（31%）取得了满意的结果。平均住院时间为42天，时长从1天到325天不等；36名患者的总费用为1,732,432美元。我们建议所有医院制定全面的方法来识别和预防这些代价高昂且不必要的事件。
