中风照护中常见的医疗疏失


  February 19, 2007 — 一篇新的研究指出在中风住院时常见的医疗疏失和不良事件。
  
  罗彻斯特医学院的研究者研究2001年7月到2004年12月之间在大型教学医院住院的中风病患,发现在173位病患有201个事件,18件是几近错误(Near miss),183 件是不良事件;183件不良事件中,86件 (46%)被认为是可预防的,37件 (20%)是无法预防的,60件 (32%) 无法确定。
  
  该研究的主要研究者Robert Holloway医师透过美国神经医学会发表声明指出,如果将这数据推算到美国所有医院每年将近100万的中风病患,将有50,000 到100,000病患会发生和疏失有关的不良事件。
  
  可预防的事件中,37% 是抄写/文件错误,23%归因于执行医嘱错误,10% 是因为照护者之间的沟通/交班错误,10%是因为独自检查失败/ 计算错误。
  
  该研究发表于2月20日的神经医学期刊。
  
  【未注意病患安全】
  根据该研究作者表示,尽管对中风的照护质量有相当多的关心,但对病患安全并没有同样的注意。
  
  他们指出大多数的事件通报系统不是仅局限于地区、不然就是特殊事件,虽然这些也是有用的信息,但无法提升对特殊疾病病患医疗疏失的了解。
  
  为了增加对中风病患的不良事件的了解,研究者使用了两个互补的事件通报系统的资料。
  
  第一个是医院内部的自主通报系统,聚焦在疏失和所谓的几近错误,其主要目标在提供事件预防;第二个是「纽约病患偶发事件通报与追踪系统(New York Patient Occurrence Reporting and Tracking System/ NYPORTS)」,一个搜集严重并发症及紧急病症,检测和治疗的强制通报系统。
  
  研究者进行主要事件分析,以确定大多数是可预防的不良事件所致;自主通报系统之148位病患的176件事件中, 72件 (41%)是跌倒,62件(36%)是医疗事件,42件 (24%)是不良临床事件。
  
  【住院天数更长】
  作者报告指出,强制通报系统之25位病患的28件事件中,都是不良临床事件且病患受到伤害;整体来看,研究者发现发生通报事件的病患,其住院天数是没有发生类似事件者的三倍长。
  
  虽然有47%的案件被归类为可预防,但作者指出,因事件类型而有不同,医疗疏失是100%可预防的,不良临床事件则有 42%是可预防的,而也有17%的跌倒事件是可预防的。
  
  研究者另外报告指出,中风后死亡之病患的通报事件比那些存活者少,他们推测,中风病患-特别是有颅内出血(ICH)者,因为中风本身具有毁灭性的本性,且有高的发病率和死亡率,因而降低了自发报告的可能性。
  
  此外,虽然跌倒事件仅有17%被认为是可预防的,发生率也较其它的研究低,但作者认为跌倒仍是中风病患安全的最大威胁之一。
  
  【警讯】
  研究也显示,ICH病患的栓塞事件风险比那些缺血性中风者高—2.6%相较于0.6%—这是一个可能冲击临床实务的研究发现。
  
  他们指出,在最初2至3周,我们的治疗实务不会对ICH病患使用低剂量肝素治疗,因为有这些不同比率,以及一个小型临床试验和已经发表的治疗规范建议,在48小时之后使用肝素预防措施可能是安全的,就应该考虑更早的预防措施。
  
  在一篇伴随而来的编辑评论中,爱荷华大学医院诊疗中心的Matthew Rizzo医师和剑桥医院的Thomas H. Glick医师表示,中风病患的可预防不良事件是一个警讯,让我们对血栓溶解剂的紧急使用有所考量。
  
  他们指出,需要更精密的通报系统和理论架构,以对明显的医疗错误和跌倒以外的不良事件加以监定和分类。
  
  神经学 2007; 68:550-555, 500-501.
  

Medical Errors Common in Strok

By Caroline Cassels
Medscape Medical News

February 19, 2007 — A new study suggests that medical errors and adverse events occur all too frequently following hospital admission for stroke.

Investigators at the University of Rochester School of Medicine in Rochester, New York, looked at all patients with strokes admitted to a large teaching hospital between July 2001 and December 2004 and found that, of a total of 201 events in 173 patients, 18 were near misses and 183 were adverse events. Of 183 adverse events, 86 (46%) were determined to be preventable, 37 (20%) were not preventable, and 60 (32%) were indeterminate.

"If these figures were applied to the nearly 1 million patients admitted to US hospitals each year for stroke, 50,000 to 100,000 patients may experience an adverse event related to an error," Robert Holloway, MD, MPH, the study's principal investigator, said in a statement from the American Academy of Neurology.

Of preventable adverse events, 37% were transcription/documentation errors, 23% were due to failure to perform a clinical task, 10% were due to communication/handoff errors between providers, and 10% were due to failed independent checks/wrong calculations.

The study was published in the February 20 issue of Neurology.

Inattention to Patient Safety

According to the study authors, despite a great deal of attention to the quality of stroke care, this has not been balanced by equal attention to patient safety.

They point out that most event-reporting systems are either location- or event-specific. Although this is useful information, the authors note, it does not increase the understanding of errors that occur in a disease-specific patient population.

To increase understanding of adverse events in patients with stroke, the investigators used data from 2 complementary event-reporting systems.

The first was the hospital's internal voluntary event-reporting system, which focuses on errors and so-called near misses. Its primary goal is to provide insight into event prevention.

The second reporting system was the New York Patient Occurrence Reporting and Tracking System (NYPORTS), a mandatory system that collects data on serious complications of acute disease, tests, and treatment.

The researchers performed a central event analysis to determine the most likely cause of preventable adverse events. Of 176 events in 148 patients in the voluntary event-reporting system, 72 (41%) were falls, 62 (36%) were medication events, and 42 (24%) were adverse clinical events.

Greater Length of Stay

The authors report that of the 28 events in 25 patients reported in the mandatory event-reporting system, all were adverse clinical events and involved patient harm.

Overall, investigators found that patients who had a reported event had a length of stay 3 times longer than patients who did not experience an adverse event.

Although 47% of events were classified as preventable, the authors note this varied by event type, with 100% of medication errors, 42% of adverse clinical events, and 17% of falls being preventable.

Researchers also reported that events were less common in stroke patients who died than in those who survived. They speculated that for stroke patients, particularly those who suffer an intracerebral hemorrhage (ICH), this might be because of the devastating nature of stroke and associated high morbidity and mortality, which may reduce the likelihood of spontaneous reporting.

In addition, although only 17% of falls were considered preventable, an incidence that is lower than that of other studies, the authors note that "falls remain one of the biggest threats to stroke-patient safety."

Wake-Up Call

The study also showed a higher risk for thromboembolic events in patients with ICH than in those with ischemic stroke—2.6% vs 0.6%—a finding that might have implications for clinical practice.

"Our practice has been not to treat ICH patients with low dose heparin for the first 2 to 3 weeks. Given these differential rates and a small clinical trial and published guidelines suggesting that heparin prophylaxis may be safe after 48 hours, earlier prophylaxis needs to be considered," they write.

In an accompanying editorial, Matthew Rizzo, MD, and Thomas H. Glick, MD, from the University of Iowa Hospitals and Clinics, Iowa City, Iowa, and The Cambridge Hospital, in Cambridge, Massachusetts, respectively, said "the documentation of preventable adverse events in stroke patients is a wake-up call for those of us who may implement acute interventions such as thrombolysis."

They highlighted the need for "more refined institutional reporting systems and theoretical frameworks for identifying and classifying adverse events beyond obvious medication errors and falls."

Neurology 2007; 68:550-555, 500-501.

    
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