Use of medical emergency team (MET) responses to detect medical errors

被引:65
作者
Braithwaite, RS
DeVita, MA
Mahidhara, R
Simmons, RL
Stuart, S
Foraida, M
机构
[1] Univ Pittsburgh, Presbyterian Hosp, Med Ctr, Dept Crit Care Med,Patient Safety Program, Pittsburgh, PA 15213 USA
[2] Univ Pittsburgh, Presbyterian Hosp, Med Ctr, Dept Surg,Patient Safety Program, Pittsburgh, PA 15213 USA
[3] Univ Pittsburgh, Presbyterian Hosp, Med Ctr, Dept Internal Med,Patient Safety Program, Pittsburgh, PA 15213 USA
来源
QUALITY & SAFETY IN HEALTH CARE | 2004年 / 13卷 / 04期
关键词
D O I
10.1136/qshc.2003.009324
中图分类号
R19 [保健组织与事业(卫生事业管理)];
学科分类号
摘要
Background: No previous studies have investigated whether medical emergency team ( MET) responses can be used to detect medical errors. Objectives: To determine whether review of MET responses can be used as a surveillance method for detecting medical errors. Methods : Charts of all patients receiving MET responses during an 8 month period were reviewed by a hospital based Quality Improvement Committee to establish if the clinical deterioration that prompted the MET response was associated with a medical error ( defined as an adverse event that was preventable with the current state of medical knowledge). Medical errors were categorized as diagnostic, treatment, or preventive errors using a descriptive typology based on previous published reports. Results: Three hundred and sixty four consecutive MET responses underwent chart review and 114 (31.3%) were associated with medical errors: 77 (67.5%) were categorized as diagnostic errors, 68 (59.6%) as treatment errors, and 30 (26.3%) as prevention errors. Eighteen separate hospital care processes were identified and modified as a result of this review, 10 of which involved standardization. Conclusions: MET review may be used for surveillance to detect medical errors and to identify and modify processes of care that underlie those errors.
引用
收藏
页码:255 / 259
页数:5
相关论文
共 27 条
[1]   Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems [J].
Barach, P ;
Small, SD .
BMJ-BRITISH MEDICAL JOURNAL, 2000, 320 (7237) :759-763
[2]   INCIDENCE OF ADVERSE EVENTS AND NEGLIGENCE IN HOSPITALIZED-PATIENTS - RESULTS OF THE HARVARD MEDICAL-PRACTICE STUDY-I [J].
BRENNAN, TA ;
LEAPE, LL ;
LAIRD, NM ;
HEBERT, L ;
LOCALIO, AR ;
LAWTHERS, AG ;
NEWHOUSE, JP ;
WEILER, PC ;
HIATT, HH .
NEW ENGLAND JOURNAL OF MEDICINE, 1991, 324 (06) :370-376
[3]   Rates of in-hospital arrests, deaths and intensive care admissions: the effect of a medical emergency team [J].
Bristow, PJ ;
Hillman, KM ;
Chey, T ;
Daffurn, K ;
Jacques, TC ;
Norman, SL ;
Bishop, GF ;
Simmons, EG .
MEDICAL JOURNAL OF AUSTRALIA, 2000, 173 (05) :236-240
[4]   Recognising clinical instability in hospital patients before cardiac arrest or unplanned admission to intensive care - A pilot study in a tertiary-care hospital [J].
Buist, MD ;
Jarmolowski, E ;
Burton, PR ;
Bernard, SA ;
Waxman, BP ;
Anderson, J .
MEDICAL JOURNAL OF AUSTRALIA, 1999, 171 (01) :22-25
[5]   Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospital: preliminary study [J].
Buist, MD ;
Moore, GE ;
Bernard, SA ;
Waxman, BP ;
Anderson, JN ;
Nguyen, TV .
BRITISH MEDICAL JOURNAL, 2002, 324 (7334) :387-390
[6]  
CHARLES V, 1998, BRIT MED J, V316, P1154
[7]   The Medical Emergency Team (MET): a model for the district general hospital [J].
Daly, FFS ;
Sidney, KL ;
Fatovich, DM .
AUSTRALIAN AND NEW ZEALAND JOURNAL OF MEDICINE, 1998, 28 (06) :795-798
[8]   Use of medical emergency team responses to reduce hospital cardiopulmonary arrests [J].
DeVita, MA ;
Braithwaite, RS ;
Mahidhara, R ;
Stuart, S ;
Foraida, M ;
Simmons, RL .
QUALITY & SAFETY IN HEALTH CARE, 2004, 13 (04) :251-254
[9]  
Goldhill DR, 1999, ANAESTHESIA, V54, P853
[10]   Incidence, location and reasons for avoidable in-hospital cardiac arrest in a district general hospital [J].
Hodgetts, TJ ;
Kenward, G ;
Vlackonikolis, L ;
Payne, S ;
Castle, N ;
Crouch, R ;
Ineson, N ;
Shaikh, L .
RESUSCITATION, 2002, 54 (02) :115-123