探討內科住院醫師在情境模擬中進行醫療錯誤揭露之影響因素

Abstract

背景：醫療錯誤揭露(medical error disclosure)是近年因應病人自主與安全文化意識運動，逐漸被重視的主題。然而過去的文獻指出，醫療錯誤被妥善告知的比例約落在兩成左右。背後潛在的因素包含對於醫療訴訟的畏懼，擔心失去病患信任，或是害怕病人及家屬的情緒反應等。而過去文獻多以問卷調查形式進行量性分析，而住院醫師的訓練過程也是承先啟後的重要階段，因此本研究希望能以質性方法針對住院醫師族群探討其醫療錯誤揭露的影響因素，並嘗試建構出架構化的模型。 方法：本研究為一質性訪談研究，以內科住院醫師為研究對象，在其完成急重症模擬訓練中的醫療錯誤揭露情境後，針對影響醫療錯誤揭露的因素進行半結構式訪談。訪談過程全程錄音並轉譯為逐字稿，繼而採用基於紮根理論的編碼方式進行編碼，最後萃取出類目及主題。質性分析過程中除了第二研究者參與分析，也會將初部結果回寄給受訪者參閱以增加研究效度。 結果：本研究於訪談22位內科住院醫師後達到理論飽和，並從中產生十個影響醫療錯誤揭露的十個類目，包含前因後果、醫療糾紛，情緒反應、告知內容，倫理價值、個人經驗，內部流程、團隊合作、支援系統及醫病關係。十個類目經過歸納後共有四個主題：事件因素、病人因素、醫師因素、系統因素，而特定類目可能歸屬至兩個主題，如告知內容與病人因素及事件因素均相關，因此提出架構化的四因子模型，用以歸類及解釋本研究結果中類目與主題的關係。 結論：本研究所產出之四因子模型，以及其下的十個類目，可以用來架構化的分析影響醫療錯誤揭露的因素，並用於設計情境模擬教案或是作為未來訓練住院醫師參考。

Background: Medical errors are encountered daily worldwide. However, less than thirty percent of medical errors were adequately disclosed to the patients. Previous studies reported that factors influencing error reporting include fear of medical disputes, losing patient’s trust and ethical issues. Residents have dual roles of both healthcare providers and learners in training, and few studies have probed this topic from residents’ perspectives. We sought to gain insight into the perspectives of resident doctors on the disclosure of medical errors and subsequently construct a comprehensive, structured model encapsulating these findings. Methods: We conducted a qualitative investigation using semi-structured interview methods on internal medicine trainees partake critical medicine training course, during which they would underwent a medical error disclosure scenario. Semi-structured interviews probing factors influencing the decision to error disclosure were conducted on residents recruited by purposive sampling. The interviews were recorded, transcribed verbatim, and subsequently coded using a grounded theory approach. In addition to involving a second researcher in the analysis, the preliminary results were sent to the interviewees for review, aiming to enhance research validity. Results: The study reached theoretical saturation following interviews with 22 residents. Ten categories regarding medical error disclosure were identified, namely causal relationship, medical disputes, emotional reactions, information to disclosure, ethical values, personal experiences, internal processes, teamwork, support systems, and physician-patient relationships. These categories were consolidated into four overarching themes: event factors, patient factors, physician factors, and system factors. Certain categories, for example, information to disclosure, related to multiple themes. Consequently, a structured four-factor model was proposed to articulate and elucidate the relationship between these categories and themes. Conclusions: The four-factor model resulting from this study, along with its constituent ten categories, serves as a robust framework for structurally analyzing factors influencing medical error disclosure. It has potential utility in designing case-based simulation curricula and as a guide for future resident doctor training programs.