医疗事故讨论 - PCP 疏忽, 延误了患者的诊治

美国医学杂志 - JAMA 刊文, 报道了一起不应发生的医疗失误. 60岁的 B 老因腰疼照了 MRI, MRI 结果意外示出 B 老先生的肾脏上有一 MASS, 疑似肿瘤. 尽管作 MRI 的医生将MRI结果送交了 Mr. B的 PCP, 但由于 MR. B 的 PCP 之疏忽, B 老先生腰子上的问题未能得到及时的确诊和治疗. 事出之后, 患者, 医生之间没有相互指责, 而是坐下来对出问题的原因作调查 .... 这篇文字就是 Mr B 的 PCP, Mr B, 以及相关医生间的对话, 讨论.

JAMA - CONFERENCES WITH PATIENTS AND DOCTORS [ 医患对话]

Medical Error - A 60-Year-Old Man With Delayed Care for a Renal Mass

Abstract

Mr B, a 60-year-old man with back pain, was not informed of an incidental finding of a renal mass suggestive of cancer on a magnetic resonance imaging scan. Failure and delays in test follow-up are a frequent problem in medicine, occurring in more than 5% of significantly abnormal ambulatory test results. Rather than simply blaming involved clinicians, systems for managing tests need to be reengineered using methods from reliability sciences. These begin with investigations into the systemic causes of the failures, then application of approaches such as heightened situational awareness, closed-loop systems, improved handoffs, just-in-time work, culture and practices of stopping to fix problems, forcing functions and simplification, enhanced visual cues, and cautious use of information technology and redundancy, all while avoiding suboptimization. Emerging test management systems and critical test follow-up recommendations illustrate how applying these principles can enhance this important aspect of patient safety.