Zusammenfassung
Hintergrund
Das Erkennen und Vermeiden von Behandlungsfehlern sind im Gesundheitswesen von großer Bedeutung. Behandlungsfehler verursachen menschliches Leid und erhebliche Kosten für die Solidargemeinschaft. Insbesondere die Kinderheilkunde und die Intensivmedizin sind betroffen.
Material und Methodik
Die Untersuchung erfolgte von März 2001 bis September 2008 freiwillig und anonym mittels eines standardisierten Formulars. Es wurden die Häufigkeit, die Art des Zwischenfalls, die betroffene Patientengruppe, die vom Meldenden angenommene Ursache sowie die Einschätzung der Gefährdung des Patienten erfasst.
Ergebnisse
Ausgewertet wurden 189 Berichte über 231 Ereignisse. Innerhalb von 3 Tagen nach dem Ereignis wurden 81,5% der Berichte abgegeben. Die Medikation des Patienten betrafen 60,6% der Meldungen, des Weiteren wurde über technische Fehlerquellen (13%) und menschliches Fehlverhalten (26,4%) berichtet. In mehr als 80% der Fälle kam es zu keiner Patientengefährdung oder erhöhtem Monitoringbedarf. Als Ursache wurden hohe Arbeitsbelastung, Unaufmerksamkeit und Fehleinschätzungen berichtet.
Schlussfolgerung
CIRS erfassen Zwischenfälle und Beinahezwischenfälle sowie deren Ursache. Das anonyme, nichtpunitive Fehlermeldesystem ermöglicht eine berufsgruppenübergreifende Auswertung von Risikoprofilen und wiederkehrenden Fehlerketten mit dem Ziel der Fehlerminimierung und Erhöhung der Patientensicherheit.
Abstract
Background
The identification and prevention of medical errors is of major interest in public health care. Medical errors result in personal harm and cause significant expenses for society. The highest error rates occur in intensive care medicine and in pediatrics.
Methods
From March 2001 to September 2008, critical incidents and adverse events were reported anonymously and voluntarily by the medical staff of a pediatric intensive care unit with the aid of a structured form. We collected information on the numbers and types of incidents, the groups of patients involved, contributing factors, and individual health risks of patients affected by these events.
Results
We analyzed 189 reports concerning 231 incidents; 81.5% of the reports were submitted within 3 days’ time. Medication errors were the concern of 60.6% of the reports. Technical problems were reported in 13% of the analyzed incidents and human errors in 26.4%. More than 80% of the analyzed incidents reported no actual harm to the patient or need for further monitoring. Major contributing factors were high census, high patient acuity, distractions, and misjudgment.
Conclusion
A critical incident reporting system (CIRS) is a powerful tool for identifying numerous medical errors and risk factors. An anonymous, nonpunitive CIRS promotes the collaborative identification of risk profiles and recurrent incidents in order to minimize medical errors and enhance patient safety.
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Berghäuser, M., Masjosthusmann, K. & Rellensmann, G. Risikomanagement durch CIRS-Analyse . Monatsschr Kinderheilkd 158, 378–383 (2010). https://doi.org/10.1007/s00112-010-2172-x
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DOI: https://doi.org/10.1007/s00112-010-2172-x