急診醫療不良事件之流行病學研究

Abstract

背景：近年來病人安全的議題受到世界各國的重視，特別是幾個探討醫療傷害的大型流行病學研究，揭露了在目前的醫療環境中存在著相當程度的疏失或危險，而在以急性住院病人為研究對象的大型研究中則指出「急診」為容易發生醫療疏失的主要場所之一，但是卻鮮少針對急診病人為對象所進行的醫療不良事件流行病學研究。 目的：本研究之主要目的在發展適合急診醫療範疇之二階段病歷審查方法，並進一步了解急診醫療不良事件之發生率與相關之流行病學特色。 方法：本研究採回溯性縱貫面研究，以某醫學中心2002年之急診病人為研究對象，隨機抽樣11382本病歷。首先，收集過去文獻上曾用於探討急診醫療錯誤的相關議題，並結合常用之急診醫療品質指標中與病人安全相關者，發展適用於急診病歷審查之篩選條件，再運用二階段病歷審查方式，將符合篩選條件之病歷由醫師進行第二階段專業審查，發掘可能的急診醫療不良事件並紀錄相關之流行病學資料。本研究除了預估急診醫療不良事件之發生率、分析急診醫療不良事件的類型與可能原因之外，並進一步探討發生急診醫療不良事件的相關風險因子與可能之預防策略。 結果：以二階段病歷審查方式推估之急診醫療不良事件發生率約為2%(95%信賴區間1.6 ~ 2.4)，而醫療不良事件中約有37%被審查者認為高度可預防性。醫療不良事件對於病人所造成的影響，多以輕度傷害為主，但是仍有約18%的病人遭致中度以上的醫療傷害。急診醫療不良事件之類型則以 ”誤診或延誤診斷” 為最多數，其次為 ”處置或監測不當” 與 ”整體評估不完整” 。病人年齡大於65歲、急診停留時間愈長、病人患有多重合併症、以及急診最終動向為死亡或住院者，則有較高的機率發生醫療不良事件，而急診停留時間則是高度可預防性醫療不良事件的重要相關因子。若以篩選條件對於急診醫療不良事件進行相關性分析，「72小時內非計畫性重返急診」、「發生醫療爭議或醫療糾紛」、「急診停留超過24小時」、「急診出院後7日內住院」、「急診初步診斷與離部診斷不一致」與急診醫療不良事件發生具有統計上之相關性。導致發生急診醫療傷害的人為因素中，則以個人因素與團隊因素兩者為主。 結論：從本研究之結果呈現有相當比例的急診病人遭受醫療不良事件，而其中亦有相當比例可透過適當的管理措施予以預防或減輕。未來可在本研究之基礎下，發展多家醫院之聯合研究模式，當可更加正確呈現本國急診醫療品質之現況與未來改善的方向。至於，醫療機構管理者亦可參考本研究結果，發展預防急診醫療不良事件提升病人安全的可行策略。

Background: Recent evidence from several epidemiology studies on medical error revealed that many patients are harmed rather than helped when encountering the healthcare system. Patient safety has become a significant public health issue since the beginning of the 21st century. Although there are many attempts to improve safety in health care, the most important aspect is to identify and eliminate risks and hazards that can cause or have the potential to cause healthcare-associated injuries. Despite of a recent published study implicating that emergency department (ED) is a key environment for preventable medical errors, there are only a few data in literature about medical injuries in emergency medicine. Objective: The aim of this research is to estimate the incidence of adverse events happened in the ED and further identify preventable and potential adverse events by using a two-phase chart review. Methods: We reviewed 11,382 randomly selected medical records from the ED of a tertiary teaching hospital in the year 2002. The first stage is a screening process done by nurses involving several criteria consisting of readily identifiable events or quality indicators associating with poor patient outcome. The secondary stage is detailed analysis of medical records positive for one of the screening criteria done by ED physicians. Randomized controls were selected and also examined by physicians. Each record is examined using a structured adverse event analysis form. Reliability and validity of this two-phase chart review process is also performed. Finally, these adverse events and their relation to error, negligence, and risk factors are analyzed and reported. Results: Adverse events occurred in 2% of patients visiting the emergency department (95% confidence interval, 1.6 to 2.4), and 37% of adverse events were considered to be highly preventable by researchers. Although most of the adverse events result in no harm or minimal injuries, 18% did cause obvious injuries to patients. “Missed or delayed diagnosis” was the most common type of adverse events, followed by “inadequate management or monitoring” and “incomplete assessment”. The probability of adverse events was highest for old age (>65 years), longer stays in ED, multiple comorbidities, and those hospitalized or died in ED. Among screening criterias used in first stage of chart review, the indicators most related to adverse events, including “unscheduled return to ED within 72 hours”, “medical litigation happened in ED”, “length of stay in ED over 24 hours”, “readmission within 7 days after ED visit”, and “discrepancy between initial and final diagnosis in ED”. Team work and personal factor were identified to be the most important to errors. Conclusions: The results of this study showed that there is a substantial amount of adverse events happened to patients in ED mostly due to medical management errors. Reducing the incidence of adverse events will require identifying their characteristics in epidemiology and developing methods to prevent errors or reduce the effects. Further population-based study may be necessary to address these adverse events thereby improving patient care in the ED.