Britt H, Miller G C, Steven I D, Howarth G C, Nicholson P A, Bhasale A L, Norton K J
Department of General Practice, University of Sydney, Westmead Hospital, NSW, Australia.
Fam Pract. 1997 Apr;14(2):101-6. doi: 10.1093/fampra/14.2.101.
The prediction and subsequent prevention of errors, which are an integral element of human behaviour, require an understanding of their cause. The incident monitoring technique was developed in the study of aviation errors in the Second World War and has been applied more recently in the field of anaesthetics. This pilot study represents one of the first attempts to apply the incident monitoring technique in the general practice environment.
A total of 297 GPs across Australia anonymously reported details of unintended events which harmed or could have harmed the patient. Reports were contemporaneously recorded on prepared forms which allowed a free text description of the incident, and structured responses for contributing and mitigating factors, immediate and long-term out-comes, additional costs etc.
The first 500 reports were analysed using both of qualitative and quantitative methods and a brief overview of results is presented. The methodological issues arising in the application of this technique to such a large, widely spread profession, in which episodes of care are not necessarily confined to a single consultation, are discussed. This study demonstrated that the incident monitoring technique can be successfully applied in general practice and that the resulting information can facilitate the identification of common factors contributing to such events and allow the development of preventive interventions.
错误作为人类行为中不可或缺的一部分,对其进行预测并随后加以预防需要了解其成因。事件监测技术是在第二次世界大战期间对航空错误的研究中发展起来的,最近已应用于麻醉领域。这项初步研究是在全科医疗环境中应用事件监测技术的首批尝试之一。
澳大利亚各地的297名全科医生匿名报告了伤害或可能伤害患者的意外事件细节。报告同时记录在预先准备好的表格上,该表格允许对事件进行自由文本描述,并对促成因素和缓解因素、即时和长期结果、额外费用等进行结构化回答。
使用定性和定量方法对前500份报告进行了分析,并给出了结果的简要概述。讨论了将该技术应用于如此庞大、分布广泛的职业(其中护理过程不一定局限于一次会诊)时出现的方法学问题。这项研究表明,事件监测技术可以在全科医疗中成功应用,并且所得到的信息有助于识别导致此类事件的常见因素,并有助于制定预防干预措施。