Lagasse R S, Steinberg E S, Katz R I, Saubermann A J
Department of Anesthesiology, State University of New York at Stony Brook, USA.
Anesthesiology. 1995 May;82(5):1181-8. doi: 10.1097/00000542-199505000-00013.
Through peer review, we separated the contributions of system error and human (anesthesiologist) error to adverse perioperative outcomes. In addition, we monitored the quality of our perioperative care by statistically defining a predictable rate of adverse outcome dependent on the system in which practice occurs and respondent to any special causes for variation.
Traditional methods of identifying human errors using peer review were expanded to allow identification of system errors in cases involving one or more of the anesthesia clinical indicators recommended in 1992 by the Joint Commission on Accreditation of Healthcare Organizations. Outcome data also were subjected to statistical process control analysis, an industrial method that uses control charts to monitor product quality and variation.
Of 13,389 anesthetics, 110 involved one or more clinical indicators of the Joint Commission on Accreditation of Healthcare Organizations. Peer review revealed that 6 of 110 cases involved two separate errors. Of these 116 errors, 9 (7.8%) were human errors and 107 (92.2%) were system errors. Attribute control charts demonstrated all indicators, excepting one (fulminant pulmonary edema), to be in statistical control.
The major determinant of our patient care quality is the system through which services are delivered and not the individual anesthesia care provider. Outcome of anesthesia services and perioperative care is in statistical control and therefore stable. A stable system has a measurable, communicable capability that allows description and prediction of the quality of care we provide on a monthly basis.
通过同行评审，我们区分了系统误差和人为（麻醉医生）误差对围手术期不良结局的影响。此外，我们通过统计确定依赖于实际操作的系统的不良结局可预测发生率，并对任何特殊变异原因做出反应，以此来监测我们围手术期护理的质量。
扩展了使用同行评审识别人为误差的传统方法，以便在涉及医疗组织评审联合委员会1992年推荐的一项或多项麻醉临床指标的病例中识别系统误差。结局数据也进行了统计过程控制分析，这是一种工业方法，使用控制图来监测产品质量和变异。
在13389例麻醉中，110例涉及医疗组织评审联合委员会的一项或多项临床指标。同行评审显示，110例病例中有6例涉及两个独立的误差。在这116个误差中，9个（7.8%）是人为误差，107个（92.2%）是系统误差。属性控制图显示，除一项（暴发性肺水肿）外，所有指标均处于统计控制状态。
我们患者护理质量的主要决定因素是提供服务的系统，而不是个体麻醉护理提供者。麻醉服务和围手术期护理的结局处于统计控制状态，因此是稳定的。一个稳定的系统具有可测量、可传达的能力，能够描述和预测我们每月提供的护理质量。
