Nature, causes and consequences of unintended events in surgical units (Br J Surg 2010; 97: 1730-1740).

摘要

Enhancing patient safety has justifiably been the subject of intense study, evaluation and reflection around the world. In 1999, the US Institute of Medicine reported that up to 88 000 patients died each year in the USA from preventable errors1. The study by van Wagtendonk and colleagues in this month's BfS provides a rigorous, structured analysis of unintended events in ten surgical units in the Netherlands, based largely on voluntary reporting by nurses. They separately report the results of retrospective chart review by experienced, trained surgeons looking for medical errors.Perhaps the most instructive data are provided in Table 3, where specific examples of the reports are provided. Although numbers and categorization somehow seem more 'scientific', data such as these are really best understood when presented descriptively. The analysis always becomes suspect when an attempt is made to convert qualitative and descriptive data into numbers and categories, as this is often a largely arbitrary and contrived exercise raising many questions. What is an 'adverse event'? Can we really precisely define a 'complication'? Who decides whether a complication is 'preventable' or 'caused' certain consequences such as death? Does a retrospective chart review really provide a comprehensive and reliable accounting of the care delivered and medical decision making to determine whether or not a complication was 'preventable'?