Patient Safety Alert Minnesota Hospital （患者安全警报明尼苏达州医院）.pptVIP

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2017-09-02 发布于浙江
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Patient Safety Alert Minnesota Hospital （患者安全警报明尼苏达州医院）.ppt

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Patient Safety Alert Minnesota Hospital （患者安全警报明尼苏达州医院）

RFO as a national issue 2003 MA closed claims study: 59% readmission or prolonged stay 69% second surgery Nearly 50% sepsis 15% fistula/small bowel obstruction 7% perforation Count Accuracy The majority of the time in RFO cases, counts are reported as correct: Gawande (2003): 88% Cima et al (2008): 62% Kaiser et al (1996): 76% Human error is predictable Why do RFO’s happen? False sense of security from a ‘correct’ sponge count. Over-reliance on diligence, even with double-checks Vena Gibbs, AHRQ Web MM: “The critical question is not Was the count correct? It is Is there a sponge or instrument in the patient? Unfortunately, we have yet to identify the best way to answer this question.” Vena Gibbs, AHRQ Web MM: “The critical question is not Was the count correct? It is Is there a sponge or instrument in the patient? Unfortunately, we have yet to identify the best way to answer this question.” Diane Rydrych Division of Health Policy MN Department of Health Overview How common are RFO nationally? How common are RFO in MN? What kinds of RFO happen in MN? Why do RFO happen? RFO as a national issue Rates difficult to come by 1/19,000? 1/9,000? 1/6,000? (VA) 1/40,000? (PA) Mortality unclear Estimates range from 11% - 35% RFO as a national issue RFO by state MD: 7* CT: 14 OR: 16 (1-9/09) NJ: 27 IN: 30 NY: ~100/year PA: 194 Note: includes only death/serious disability RFO in Minnesota Type of procedure What was retained? When was the RFO discovered? Patient Outcomes Count Done? 0.25 General error in high stress when dangerous activities occurring rapidly 0.1 Personnel on different shifts fail to check hardware unless required by checklist 0.1 Monitor or inspector fails to detect error 0.03 Simple math error with self-checking 0.003 Error of omission when items imbedded in a procedure 0.01 Error of omission without reminders 0.003 Error of commission (misreading a label) Probability Activity Salvendy G. Handbook of Human Factors Ergonomics, 1997 Count Correct? Risk