醫療錯誤相關因素探討--以外科醫療為例

Factors Associated with Medical Error---For Example of Surgery

郭萃華(Tsui-Hui Kuo)

指導教授 ： 陳端容

國立臺灣大學/公共衛生學院/醫療機構管理研究所/碩士(2005年)

https://doi.org/10.6342/NTU.2005.02968

摘要

世界病人安全聯盟(World Aliance for Patient Safety)於2004年正式宣告所有醫療照顧須為促進病人安全而努力；同時指出醫療應以知識、資源共享為依歸，減少重複投資與非必要醫療處置，以提高醫療效率與效益。因此，病人安全已成為二十一世紀醫療照顧最重要的議題。依文獻上統計所有醫療不良事件中，外科醫療不良事件約佔66%的比例；然而在臺灣，外科醫療錯誤的分佈情形，造成外科醫療錯誤的因素為何？之前卻少有相關研究深入探討。
　　本研究以本研究以行政院衛生署”九十二年醫院評鑑及教學醫院評鑑合格名單”為標準，並由全國外科醫學會及醫師公會名單中選取地區教學醫院(含)以上層級之醫院之外科醫師(醫師指具專業外科證照，且目前登記執業，並在地區教學醫院(含)以上服務之外科醫師)為研究對象，將外科醫師年齡、年資等個人特質與專業訓練，工作狀況，醫院作業環境為自變項，醫師自已曾經發生
醫療錯誤(自覺診斷、術前、術中、術後、溝通、用藥之錯誤)為依變項，郵寄設計問卷，回收331份，回收率13.59%。另並設計訪談大綱，與10位外科醫師進行面對面深入訪談。
　　研究結果發現：外科醫師認為醫療錯誤之發生原因中，人為因素中最可能者為：手術經驗不足、疲倦、整體工作壓力太大。工作及流程相關因素中最可能者為：與病患或家屬溝通不良、專業訓練不足、缺乏資深醫師指導。組織因素中最可能者為：人力配置不足、缺乏標準作業流程(SOP)、行政管理缺失。在各類型之醫療錯誤中(診齗錯誤、術前準備錯誤術中處理錯誤、術後照顧錯誤、用藥錯誤、溝通錯誤)，發現不論是自已曾經發生或觀察他人發生的錯誤分佈中，均顯示最多為術後照顧錯誤及診斷錯誤。
　　外科醫師學歷為碩博士者，發生外科醫療錯誤的情況顯著降低。外科醫師執行手術時，被電話或呼叫器干擾而中斷的頻率愈高者，其發生外科醫療錯誤的情況顯著昇高。檢查檢驗報告異常時，愈常主動通知開單醫師者，外科醫師發生外科醫療錯誤的情況顯著降低。
　　由本研究最終分析結果，外科醫師學歷為碩博士者，執行手術時，愈少被電話或呼叫器干擾而中斷者，檢查檢驗報告異常時，愈常主動通知開單醫師者，發生外科醫療錯誤的情況較少。
　　建議：國內應發展建立外科醫師對醫療錯誤相關名詞範圍之界定與共識，持續提昇醫師人本精神的觀念。醫院宜加強要求檢查檢驗報告異常值時主動通知，並須對院內同仁加強醫院宣導，如醫師在執行手術時，應建立防止干擾如電話、行動電話、呼叫器等之管理機制，或必需強制要求醫護人員執行醫療業務時禁止使用。另醫院仍應儘量多提供臨床資訊管道，多鼓勵醫師專業進修，並要求科內同仁落責會議討論，並應發展建立不具名之手術不良事件通報系統；醫師之工作時數在合理範圍內，落實每一工作人員對病人安全重視，從而改善外科就醫環境。

關鍵字

外科醫療錯誤 ； 醫院作業環境 ； 工作狀況 ； 外科醫療不良事件 ； 醫師專業程度 ； 病人安全

並列摘要

The World Aliance for Patient Safety created in 2004 ensured that the drive for safer health care is now becoming a worldwide endeavour that can bring significant benefits to patients in countries rich and poor, developed and developing, in all corners of the globe. It provides a mechanism to build capacity, decrease duplication of investment and activities and benefit by economies of scale also. The Patient Safety issue becomes the most important one in 21 th century. There were about 66% cases from surgery who suffered from medical adverse events. But here in Taiwan, there is no knowing about the medical error distributions in surgery, nor do we know the factors which associated with the surgical medical errors.
The study takes surgeons selected out of the community-based level hospitals (including & upon) accredited with the Department of Health ( DOH) in 2003 as the samples. The questionnaire was designed to be aimed at the individual backgrounds, experiences accumulated, professionalism, work conditions, environment, these as the independent variables. The perceived categories of surgical medical error( include diagnosis, preoperative preparation, intra-operative manangement, postoperative monitoring, medicine, communication error) as the dependent variables. A total of 331 copies of the questionnaires were successfully retrieved. The rough estimate indicates a successful retrieval rate of 13.59 %.
The findings yielded through the study indicate that in personal professionalism , surgeons graduated with the degree of master or PHD. responded with fewer medical error than surgeons with MD. Surgeons of more interruptions during surgery responded with more medical errors than those who did not. Surgeons who received more abnormal data remind responded with fewer medical errors than those who did not. Otherwise, the most medical errors was found during postoperative caring & monitoring and diagnosis. And the causes were multifactorial; human engineering,(such as tired, stress, no enough experience) work conditions( such as poor communication with patient & family, poor professionalism, unavailable senior surgeon instrument), organizations factors or team work( such as substandard manpower, short of standard of procedures, administrative deficiency).
Comment: It’s necessary to set up standard taxonomy in surgical medical errors here in Taiwan. The ethical education programs for surgeon should be launched continually. The interruptions during surgery should be forbidden. The abnormal laboratory data should be reminded for surgeons in time.

並列關鍵字

team work ； patient safety ； work condition ； surgeon ； professionalism ； medical error ； adverse event

參考文獻

陳榮基，醫療糾紛的預防,1998

邱文達、石崇良、侯勝茂，建構以病人為中心的醫療體系,2004

行政院衛生署醫政處醫療鑑定小組歷年受委託案件統計，2003

National Quality Forum

Abramson NS, Wald KS, Grenvik AN, et al.(1980) Adverse occurrences in intensive care units. J.A.M.A.244: 1582–1584.