Runciman W B, Helps S C, Sexton E J, Malpass A
Department of Anaesthesia and Intensive Care, Royal Adelaide Hospital and University of Adelaide, SA, Australia.
J Qual Clin Pract. 1998 Sep;18(3):199-211.
Problems that arise from health-care management, rather than from a disease process, are now recognized as making a substantial contribution to patient morbidity and mortality and to the cost of health care. However, most classifications of these problems do not provide sufficient detail to allow comparisons or to develop better strategies for the prevention, detection and management of these problems. A 'Generic Occurrence Classification' was developed to record their salient features, place them in context and elicit any system or human error-based contributing factors. This was done by an iterative process in which 'natural categories', identified from over 2000 incidents and 800 adverse events, were placed in a hierarchical structure created using software written in Microsoft Visual Basic; data were stored in a Microsoft Access database. This was shown to be a valid and reliable way to compare incidents and accidents from different sources and to allow sufficient detail to be retrieved to develop preventive strategies.
现在人们认识到,由医疗保健管理而非疾病过程引发的问题,对患者的发病率和死亡率以及医疗保健成本有着重大影响。然而,这些问题的大多数分类都没有提供足够的细节,以便进行比较或制定更好的预防、检测和管理这些问题的策略。开发了一种“通用事件分类法”来记录它们的显著特征,将它们置于背景中,并找出任何基于系统或人为错误的促成因素。这是通过一个迭代过程完成的,在这个过程中,从2000多起事件和800起不良事件中识别出的“自然类别”被放置在一个使用微软Visual Basic编写的软件创建的层次结构中;数据存储在微软Access数据库中。事实证明,这是一种有效且可靠的方法,可用于比较来自不同来源的事件和事故,并获取足够的细节以制定预防策略。