Anuj K Dalal, Savanna Plombon, Kaitlyn Konieczny, Daniel Motta-Calderon, Maria Malik, Alison Garber, Alyssa Lam, Nicholas Piniella, Marie Leeson, Pamela Garabedian, Abhishek Goyal, Stephanie Roulier, Cathy Yoon, Julie M Fiskio, Kumiko O Schnock, Ronen Rozenblum, Jacqueline Griffin, Jeffrey L Schnipper, Stuart Lipsitz, David W Bates
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引用次数: 0
Abstract
Background: Adverse event surveillance approaches underestimate the prevalence of harmful diagnostic errors (DEs) related to hospital care.
Methods: We conducted a single-centre, retrospective cohort study of a stratified sample of patients hospitalised on general medicine using four criteria: transfer to intensive care unit (ICU), death within 90 days, complex clinical events, and none of the aforementioned high-risk criteria. Cases in higher-risk subgroups were over-sampled in predefined percentages. Each case was reviewed by two adjudicators trained to judge the likelihood of DE using the Safer Dx instrument; characterise harm, preventability and severity; and identify associated process failures using the Diagnostic Error Evaluation and Research Taxonomy modified for acute care. Cases with discrepancies or uncertainty about DE or impact were reviewed by an expert panel. We used descriptive statistics to report population estimates of harmful, preventable and severely harmful DEs by demographic variables based on the weighted sample, and characteristics of harmful DEs. Multivariable models were used to adjust association of process failures with harmful DEs.
Results: Of 9147 eligible cases, 675 were randomly sampled within each subgroup: 100% of ICU transfers, 38.5% of deaths within 90 days, 7% of cases with complex clinical events and 2.4% of cases without high-risk criteria. Based on the weighted sample, the population estimates of harmful, preventable and severely harmful DEs were 7.2% (95% CI 4.66 to 9.80), 6.1% (95% CI 3.79 to 8.50) and 1.1% (95% CI 0.55 to 1.68), respectively. Harmful DEs were frequently characterised as delays (61.9%). Severely harmful DEs were frequent in high-risk cases (55.1%). In multivariable models, process failures in assessment, diagnostic testing, subspecialty consultation, patient experience, and history were significantly associated with harmful DEs.
Conclusions: We estimate that a harmful DE occurred in 1 of every 14 patients hospitalised on general medicine, the majority of which were preventable. Our findings underscore the need for novel approaches for adverse DE surveillance.
背景:不良事件监测方法低估了与医院护理相关的有害诊断错误(DE)的发生率:我们对普通内科住院患者进行了一项单中心、回顾性队列研究,采用四个标准对患者进行分层抽样:转入重症监护室(ICU)、90 天内死亡、复杂临床事件以及不符合上述高风险标准。高风险亚组中的病例按预先确定的百分比进行超额抽样。每个病例都由两名经过培训的评审员进行审查,评审员的职责包括:使用 "更安全的诊断 "工具判断发生 DE 的可能性;描述危害、可预防性和严重性;使用针对急症护理修改的 "诊断错误评估和研究分类标准 "识别相关的流程故障。专家小组对存在差异或不确定诊断错误或影响的病例进行了审查。我们使用描述性统计方法,根据加权样本的人口统计学变量和有害 DE 的特征,报告有害、可预防和严重有害 DE 的人口估计值。我们使用多变量模型来调整流程故障与有害 DE 之间的关联:在 9147 例符合条件的病例中,每个分组随机抽取了 675 例:100%的ICU转院病例、38.5%的90天内死亡病例、7%的复杂临床事件病例和2.4%的无高风险标准病例。根据加权样本,有害、可预防和严重有害死亡病例的人群估计值分别为7.2%(95% CI 4.66至9.80)、6.1%(95% CI 3.79至8.50)和1.1%(95% CI 0.55至1.68)。有害的 DE 经常被描述为延迟(61.9%)。高风险病例(55.1%)中经常出现严重有害的 DE。在多变量模型中,评估、诊断检测、亚专科会诊、患者经历和病史方面的流程失误与有害 DE 有显著相关性:我们估计,每14名住院的普通内科病人中就有1人发生了有害的死亡病例,其中大部分是可以预防的。我们的研究结果表明,有必要采用新方法对有害 DE 进行监控。
期刊介绍:
BMJ Quality & Safety (previously Quality & Safety in Health Care) is an international peer review publication providing research, opinions, debates and reviews for academics, clinicians and healthcare managers focused on the quality and safety of health care and the science of improvement.
The journal receives approximately 1000 manuscripts a year and has an acceptance rate for original research of 12%. Time from submission to first decision averages 22 days and accepted articles are typically published online within 20 days. Its current impact factor is 3.281.