Petersen L A, Brennan T A, O'Neil A C, Cook E F, Lee T H
Brigham and Women's Hospital, Boston, MA.
Ann Intern Med. 1994 Dec 1;121(11):866-72. doi: 10.7326/0003-4819-121-11-199412010-00008.
To study the relation between housestaff coverage schedules and the occurrence of preventable adverse events.
Case-control study.
Urban teaching hospital.
All 3146 patients admitted to the medical service during a 4-month period.
A previously tested confidential self-report system to identify adverse events, which were defined as unexpected complications of medical therapy that resulted in increased length of stay or disability at discharge. A panel of three board-certified internists confirmed events and evaluated preventability based on case summaries. Housestaff coverage was coded according to the day in the usual intern's schedule and to cross-coverage status. Cross-coverage was defined as care by a house officer who was not the patient's usual intern and not a member of the usual intern's patient care team. Coverage for an adverse event was assigned according to who was covering during the proximate cause of that event. Clinical data were collected for each patient and two matched controls.
Of the 124 adverse events reported and confirmed, 54 (44%) were judged potentially preventable. In the univariate analysis, patients with potentially preventable adverse events were more likely than their controls to be covered by a physician from another team at the time of the event (26% compared with 12% [odds ratio, 3.5; P = 0.01]). In the multivariate analysis, three factors were significant independent correlates of potentially preventable adverse events; cross-coverage (odds ratio, 6.1; 95% CI, 1.4 to 26.7), Acute Physiology and Chronic Health Evaluation II score (odds ratio per point, 1.2; CI, 1.1 to 1.4), and history of gastrointestinal bleeding (odds ratio, 4.7; CI, 1.2 to 19.0).
Potentially preventable adverse events were strongly associated with coverage by a physician from another team, which may reflect management by housestaff unfamiliar with the patient. The results emphasize the need for careful attention to the outcome of work-hour reforms for housestaff.
研究住院医师值班安排与可预防不良事件发生之间的关系。
病例对照研究。
城市教学医院。
4个月期间内科收治的所有3146例患者。
采用先前测试过的保密自我报告系统来识别不良事件，不良事件定义为医疗治疗中导致住院时间延长或出院时出现残疾的意外并发症。由三名获得委员会认证的内科医生组成的小组根据病例摘要确认事件并评估可预防性。住院医师值班情况根据常规实习医生排班表中的日期和交叉值班状态进行编码。交叉值班定义为由非患者常规实习医生且非常规实习医生患者护理团队成员的住院医生提供护理。根据不良事件直接原因发生期间的值班人员来确定该不良事件的值班情况。收集了每位患者及其两名匹配对照的临床数据。
在报告并确认的124例不良事件中，54例（44%）被判定为可能可预防。在单因素分析中，发生可能可预防不良事件的患者在事件发生时由另一团队医生值班的可能性高于其对照患者（分别为26%和12%[优势比，3.5；P = 0.01]）。在多因素分析中，三个因素是可能可预防不良事件的显著独立相关因素；交叉值班（优势比，6.1；95%置信区间，1.4至26.7）、急性生理与慢性健康状况评价II评分（每分优势比，1.2；置信区间，1.1至1.4）以及胃肠道出血史（优势比, 4.7；置信区间，1.2至19.0）。
可能可预防的不良事件与另一团队医生值班密切相关，这可能反映了不熟悉患者情况的住院医师进行的管理。结果强调需要密切关注住院医师工作时间改革的结果。
