Through peer review, we separated the contributions of system error and human (anesthesiologist) error to adverse perioperative outcomes.
In addition, we monitored the quality of our perioperative care by statistically defining a predictable rate of adverse outcome dependent on the system in which practice occurs and respondent to any special causes for variation.
Traditional methods of identifying human errors using peer review were expanded to allow identification of system errors in cases involving one or more of the anesthesia clinical indicators recommended in 1992 by the joint Commission on Accreditation of Healthcare Organizations.
Outcome data also were subjected to statistical process control analysis, an industrial method that uses control charts to monitor product quality and variation.
Of 13,389 anesthetics, 110 involved one or more clinical indicators of the joint Commission on Accreditation of Healthcare Organizations.
Peer review revealed that 6 of 110 cases involved two separate errors.
Of these 116 errors, 9 (7.8%) were human errors and 107 (92.2%) were system errors.
Attribute control charts demonstrated all indicators, excepting one (fulminant pulmonary edema), to be in statistical control.
The major determinant of our patient care quality is the system through which services are delivered and not the individual anesthesia care provider.
Mots-clés Pascal : Contrôle qualité, Soin, Peropératoire, Chirurgie, Complication, Assurance qualité, Hôpital, Etats Unis, Amérique du Nord, Amérique
Mots-clés Pascal anglais : Quality control, Care, Intraoperative, Surgery, Complication, Quality assurance, Hospital, United States, North America, America
Notice produite par :
Inist-CNRS - Institut de l'Information Scientifique et Technique
Cote : 95-0344645
Code Inist : 002B30A04D. Création : 01/03/1996.