ContextMedical errors are associated with feelings of distress in physicians, but little is known about the magnitude and direction of these associations.ObjectiveTo assess the frequency of self-perceived medical errors among resident physicians and to determine the association of self-perceived medical errors with resident quality of life, burnout, depression, and empathy using validated metrics.Design, Setting, and ParticipantsProspective longitudinal cohort study of categorical and preliminary internal medicine residents at Mayo Clinic Rochester. Data were provided by 184 (84%) of 219 eligible residents. Participants began training in the 2003-2004, 2004-2005, and 2005-2006 academic years and completed surveys quarterly through May 2006. Surveys included self-assessment of medical errors and linear analog scale assessment of quality of life every 3 months, and the Maslach Burnout Inventory (depersonalization, emotional exhaustion, and personal accomplishment), Interpersonal Reactivity Index, and a validated depression screening tool every 6 months.Main Outcome MeasuresFrequency of self-perceived medical errors was recorded. Associations of an error with quality of life, burnout, empathy, and symptoms of depression were determined using generalized estimating equations for repeated measures.ResultsThirty-four percent of participants reported making at least 1 major medical error during the study period. Making a medical error in the previous 3 months was reported by a mean of 14.7% of participants at each quarter. Self-perceived medical errors were associated with a subsequent decrease in quality of life (P = .02) and worsened measures in all domains of burnout (P = .002 for each). Self-perceived errors were associated with an odds ratio of screening positive for depression at the subsequent time point of 3.29 (95% confidence interval, 1.90-5.64). In addition, increased burnout in all domains and reduced empathy were associated with increased odds of self-perceived error in the following 3 months (P=.001, P<.001, and P=.02 for depersonalization, emotional exhaustion, and lower personal accomplishment, respectively; P=.02 and P=.01 for emotive and cognitive empathy, respectively).ConclusionsSelf-perceived medical errors are common among internal medicine residents and are associated with substantial subsequent personal distress. Personal distress and decreased empathy are also associated with increased odds of future self-perceived errors, suggesting that perceived errors and distress may be related in a reciprocal cycle.

https://jamanetwork.com/journals/jama/articlepdf/203249/joc60109.pdf

Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study.

DivisionofGeneralInternalMedi-cine, Department of Medicine (Dr West), Division ofBiostatistics, Department of Health Sciences Re-search(DrSloan,MsHuschka,andMrNovotny),Di-vision of Gastroenterology and Hepatology, Depart-ment of Medicine (Dr Kolars) and Division ofHematology, Department of Medicine (DrsHabermann and Shanafelt), Mayo Clinic College ofMedicine, Rochester, Minn.

Association of Perceived Medical Errors With Resident Distress and Empathy

Objective: The aim of this systematic review was to develop a ‘contributory factors framework’ from a synthesis of empirical work which summarises factors contributing to patient safety incidents in hospital settings. Design: A mixed-methods systematic review of the literature was conducted. Data sources: Electronic databases (Medline, PsycInfo, ISI Web of knowledge, CINAHL and EMBASE), article reference lists, patient safety websites, registered study databases and author contacts. Eligibility criteria: Studies were included that reported data from primary research in secondary care aiming to identify the contributory factors to error or threats to patient safety. Results: 1502 potential articles were identified. 95 papers (representing 83 studies) which met the inclusion criteria were included, and 1676 contributory factors extracted. Initial coding of contributory factors by two independent reviewers resulted in 20 domains (eg, team factors, supervision and leadership). Each contributory factor was then coded by two reviewers to one of these 20 domains. The majority of studies identified active failures (errors and violations) as factors contributing to patient safety incidents. Individual factors, communication, and equipment and supplies were the other most frequently reported factors within the existing evidence base. Conclusions: This review has culminated in an empirically based framework of the factors contributing to patient safety incidents. This framework has the potential to be applied across hospital settings to improve the identification and prevention of factors that cause harm to patients.

https://www.improvementacademy.org/documents/Projects/safety_incidents_framwork/Development%20of%20an%20evidence-based%20framework.pdf

Development of an evidence-based framework of factors contributing to patient safety incidents in hospital settings: a systematic review

In high-risk industries such as aviation, the skills not related directly to technical expertise, but crucial for maintaining safety (e.g. teamwork), have been categorized as non-technical skills. Recently, research in anaesthesia has identified and developed a taxonomy of the non-technical skills requisite for safety in the operating theatre. Although many of the principles related to performance and safety within anaesthesia are relevant to the intensive care unit (ICU), relatively little research has been done to identify the non-technical skills required for safe practice within the ICU. This review focused upon critical incident studies in the ICU, in order to examine whether the contributory factors identified as underlying the critical incidents, were associated with the skill categories (e.g. task management, teamwork, situation awareness and decision making) outlined in the Anaesthetists' Non-technical Skills (ANTS) taxonomy. We found that a large proportion of the contributory factors underlying critical incidents could be attributed to a non-technical skill category outlined in the ANTS taxonomy. This is informative both for future critical incident reporting, and also as an indication that the ANTS taxonomy may provide a good starting point for the development of a non-technical skills taxonomy for intensive care. However, the ICU presents a range of unique challenges to practitioners working within it. It is therefore necessary to conduct further non-technical skills research, using human factors techniques such as root-cause analyses, observation of behaviour, attitudinal surveys, studies of cognition, and structured interviews to develop a better understanding of the non-technical skills important for safety within the ICU. Examples of such research highlight the utility of these techniques.

/pdf/non-technical-skills-in-the-intensive-care-unit-18g581r84p.pdf

Non-technical skills in the intensive care unit

Rationale: Although intensive care units (ICUs) were created for patients with life-threatening illnesses, the ICU environment generates a high risk of iatrogenic events. Identifying medical errors (MEs) that serve as indicators for iatrogenic risk is crucial for purposes of reporting and prevention.Objectives: We describe the selection of indicator MEs, the incidence of such MEs, and their relationship with mortality.Methods: We selected indicator MEs using Delphi techniques. An observational prospective multicenter cohort study of these MEs was conducted from March 27 to April 3, 2006, in 70 ICUs; 16 (23%) centers were audited. Harm from MEs was collected using specific scales.Measurements and Main Results: Fourteen types of MEs were selected as indicators; 1,192 MEs were reported for 1,369 patients, and 367 (26.8%) patients experienced at least 1 ME (2.1/1,000 patient-days). The most common MEs were insulin administration errors (185.9/1,000 d of insulin treatment). Of the 1,192 medical errors, 183 (15...

https://www.atsjournals.org/doi/pdf/10.1164/rccm.200812-1820OC

Selected medical errors in the intensive care unit: results of the IATROREF study: parts I and II.

Background: To assess the frequency, type, consequences, and associations of errors and incidents in a medical intensive care unit (ICU).

Methods:  Two-hundred and sixteen consecutive patients with predominantly cardiovascular and pulmonary disorders admitted between December 2002 and February 2003 were enrolled. Demographic data, SAPS II, and TISS-28 were obtained for all patients. Prior to patient enrolment all staff members (physicians, nurses, physiotherapists) were repeatedly encouraged to make use of the Incident Report Form (IRF) and detailed descriptions on how, why and when to use the IRF were provided.

Results:  During the observation period of 64 days, 50 errors involving 32 patients (15%) were reported. Patients subjected to errors were more severely ill (SAPS II 42 ± 25 vs. 32 ± 18, P < 0.05), had a higher hospital mortality (38% vs. 9%), and a longer ICU stay (11 ± 18 vs. 3 ± 5 days, P < 0.05). Gender, age and TISS-28 were equally distributed. Each day of ICU stay increased the risk by 8% (odds ratio 1.078, 95% confidence interval 1.034–1.125, P < 0.001), and by 2.3% per SAPS II point (odds ratio 1.023, 95% confidence interval 1.006–1.040, P < 0.001). The majority of errors and incidents were judged as ‘human failures’ (73%), and 46 errors and incidents (92%) as ‘avoidable’.

Conclusions:  The identification and characterization of errors and incidents combined with contextual information is feasible and may provide sufficient background information for areas of quality improvement. Areas with a high frequency of errors and incidents need to undergo process evaluation to avoid future occurrence.

Identification and characterization of errors and incidents in a medical intensive care unit.

Gegenwartig verstirbt etwa die Halfte aller Menschen in Deutschland im Krankenhaus und ein groser Teil dieser Patienten verbringt die letzte Lebens- bzw. Sterbensphase auf der Intensivstation. Fur das intensivmedizinische Team stellt der Umgang mit Sterben und Tod somit einen wesentlichen Teil des beruflichen Alltags dar. Neben dem Patienten gilt es aber auch, sich intensiv den Angehorigen dieser Patienten zu widmen, die haufig dem Erleben von Leid, Sterben und Tod hilflos gegenuber stehen. Zu selten werden im professionell-medizinischen Umfeld der Intensivstation diese wichtigen Aspekte der Angehorigenbegleitung berucksichtigt: es fehlen Raumlichkeiten, Zeit und Ausbildung im Umgang mit emotional schwer belasteten Angehorigen.

Das Unfassbare verstehen: Kommunikation mit Angehörigen von sterbenden Patienten auf der Intensivstation

Fehler und Zwischenfalle sind in der Medizin haufig, und besonders Bereiche mit hoher Arbeitsbelastung und schwer kranken Patienten wie die Intensivmedizin sind somit potenziell anfallig fur das Auftreten unerwunschte Ereignisse. Die in der Intensivmedizin vorherrschenden Rahmenbedingungen bezeichnen Psychologen als „kognitiv komplexes Umfeld“. Im Rahmen der Tatigkeiten des Intensivmediziners nimmt die mundliche und schriftliche Nachrichtenubermittlung, d. h. Kommunikation, aufgrund der vielen Schnittstellen der innerbetrieblichen Organisation und Patientenversorgung eine herausragende Rolle ein. Kommunikationsschwierigkeiten, d. h. Missverstandnisse oder das Fehlen notwendiger Kommunikation, stellen in der (Intensiv-)Medizin ein relevantes und alltagliches Problem dar. Weniger eindeutig sind die Vorstellungen, wie die Kommunikation im (intensiv)medizinischen Team verbessert werden kann.

Kommunikation – ein Missverständnis?!

Um den vielfaltigen Herausforderungen der Intensivmedizin im Spannungsfeld zwischen klinischer Patientenversorgung, medizinisch-wissenschaftlichem Fortschritt, okonomischen Limitationen, Ethik und Moral, und den Anforderungen der Aus-, Fort- und Weiterbildung zukunftig gerecht werden zu konnen erscheint eine grundlegende Neuausrichtung der Intensivmedizin in Deutschland unumganglich. Ohne ein strukturiertes Qualitatsmanagement wird diese Aufgabe nicht bewaltigt werden konnen.

/pdf/qualitatsmanagement-in-der-intensivmedizin-81sy6015od.pdf

Qualitätsmanagement in der Intensivmedizin

Gegenwartig entsteht der Eindruck, Qualitatssicherung bzw. Qualitatsmanagement seien moderne industrielle Errungenschaften. Hierbei wird ubersehen, dass es bereits im 19. Jahrhundert und zu Beginn des 20. Jahrhunderts mit dem Bostoner Chirurgen Earnest A. Codman, MD, Entwicklungen hin zur Qualitatssicherung in der Medizin gegeben hat. Mitte des 20. Jahrhunderts wurden diese Initiativen unter anderem von Avedis Donabedian, MD, strukturell und auch inhaltlich weiter gefuhrt. Viele der fruher und auch heute noch in der Medizin eingesetzten Instrumente und Konzepte der Qualitatssicherung kommen ursprunglich aus der Industrie. Dieser Beitrag stellt die wesentlichsten Entwicklungsschritte der ersten 100 Jahre Qualitatssicherung bzw. Qualitatsmanagement in Medizin und Industrie dar.

Historie des Qualitätsmanagements

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