Skip to main content
Top

2006 | OriginalPaper | Hoofdstuk

5 De epidemiologie van medische fouten, medische: weten we wel wat we meten?

Auteur : R.W.M. Giard

Gepubliceerd in: Praktijkboek patiëntveiligheid

Uitgeverij: Bohn Stafleu van Loghum

share
DELEN

Deel dit onderdeel of sectie (kopieer de link)

  • Optie A:
    Klik op de rechtermuisknop op de link en selecteer de optie “linkadres kopiëren”
  • Optie B:
    Deel de link per e-mail

Samenvatting

In de voorgaande hoofdstukken is duidelijk gemaakt dat patiëntveiligheid continu aandacht verdient: het is zowel een onderschat als een structureel probleem, niet maar een handjevol incidenten. Het is om verschillende redenen belangrijk om onderzoek te doen naar de frequentie van fouten. Hoe vaak worden er fouten gemaakt? Welke verschillen bestaan er tussen foutfrequenties van artsen, ziekenhuizen, regio’s en landen? Wat kunnen we te weten komen over de oorzaken van misslagen? Hebben maatregelen die genomen worden voor verbetering van de patiëntveiligheid ook daadwerkelijk effect in de zin van minder iatrogene schade en minder slachtoffers?1,2 Dat vraagt nauwgezet en systematisch onderzoek van de medische praktijk.
Literatuur
1.
go back to reference Brennan TA, Gowanda A, Thomas E, Studdert D. Accidental deaths, saved lives, and improved quality. N Engl J Med 2005;353:1405–9.CrossRefPubMed Brennan TA, Gowanda A, Thomas E, Studdert D. Accidental deaths, saved lives, and improved quality. N Engl J Med 2005;353:1405–9.CrossRefPubMed
3.
go back to reference Wetenschappelijke Raad voor het Regeringsbeleid. Bewijzen van goede dienstverlening. Hoofdstuk 7: Leren en controleren. Amsterdam: Amsterdam University Press, 2004, p. 185–216. Wetenschappelijke Raad voor het Regeringsbeleid. Bewijzen van goede dienstverlening. Hoofdstuk 7: Leren en controleren. Amsterdam: Amsterdam University Press, 2004, p. 185–216.
4.
go back to reference Reason J. Human error. Cambridge: Cambridge University Press 1990, p. 9.CrossRef Reason J. Human error. Cambridge: Cambridge University Press 1990, p. 9.CrossRef
5.
6.
go back to reference Battles JB, Lilford RJ. Organizing patient safety research to identify risks and hazards. Qual Saf Health Care 2003;12(Suppl 2):ii2–7.PubMed Battles JB, Lilford RJ. Organizing patient safety research to identify risks and hazards. Qual Saf Health Care 2003;12(Suppl 2):ii2–7.PubMed
7.
go back to reference Hofer TP, Kerr EA, Hayward RA. What is an error? Effect Clin Pract 2000;3:261–9. Hofer TP, Kerr EA, Hayward RA. What is an error? Effect Clin Pract 2000;3:261–9.
8.
go back to reference Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med 1991;324:370–6.CrossRefPubMed Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med 1991;324:370–6.CrossRefPubMed
9.
go back to reference Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Newby L, Hamilton JD. The Quality in Australian Health Care Study. Med J Aust 1995;163:458–71.PubMed Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Newby L, Hamilton JD. The Quality in Australian Health Care Study. Med J Aust 1995;163:458–71.PubMed
11.
go back to reference Baker GR, Norton PG, Flintoft V, Blais R, Brown A, Cox J, et al. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ 2004;170:1678–86.PubMedCentralCrossRefPubMed Baker GR, Norton PG, Flintoft V, Blais R, Brown A, Cox J, et al. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ 2004;170:1678–86.PubMedCentralCrossRefPubMed
12.
go back to reference Michel P, Quenon JL, Djihoud A, Tricaud-Vialle S, Sarasqueta AM de, Domecq S. Les événements indésirables graves liés aux soins observés dans les établissements de santé: premiers résultats d’une étude nationale. Études et résultats 2005;No. 398:1–15. Michel P, Quenon JL, Djihoud A, Tricaud-Vialle S, Sarasqueta AM de, Domecq S. Les événements indésirables graves liés aux soins observés dans les établissements de santé: premiers résultats d’une étude nationale. Études et résultats 2005;No. 398:1–15.
13.
go back to reference Neale G, Woloshynowych M. Retrospective case record review: a blunt instrument that needs sharpening. Qual Saf Health Care 2003 Feb;12(1):2–3. Neale G, Woloshynowych M. Retrospective case record review: a blunt instrument that needs sharpening. Qual Saf Health Care 2003 Feb;12(1):2–3.
14.
go back to reference Lilford RJ, Mohammed MA, Braunholtz D, Hofer TP. The measurement of active errors: methodological issues. Qual Saf Health Care 2003;12(Suppl 2):ii8–12.PubMed Lilford RJ, Mohammed MA, Braunholtz D, Hofer TP. The measurement of active errors: methodological issues. Qual Saf Health Care 2003;12(Suppl 2):ii8–12.PubMed
15.
go back to reference Forster AJ, Clark HD, Menard A, Dupuis N, Chernish R, Chandok N, et al. Adverse events among medical patients after discharge from hospital. CMAJ 2004;170:345–9.PubMedCentralPubMed Forster AJ, Clark HD, Menard A, Dupuis N, Chernish R, Chandok N, et al. Adverse events among medical patients after discharge from hospital. CMAJ 2004;170:345–9.PubMedCentralPubMed
16.
go back to reference Zhan C, Miller MR. Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization. JAMA 2003;290:1868–74.CrossRefPubMed Zhan C, Miller MR. Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization. JAMA 2003;290:1868–74.CrossRefPubMed
17.
go back to reference Andrews LB, Stocking C, Krizek T, Gottlieb L, Krizek C, Vargish T, et al. An alternative strategy for studying adverse events in medical care. Lancet 1997;349:309–13.CrossRefPubMed Andrews LB, Stocking C, Krizek T, Gottlieb L, Krizek C, Vargish T, et al. An alternative strategy for studying adverse events in medical care. Lancet 1997;349:309–13.CrossRefPubMed
18.
go back to reference Donchin Y, Gopher D, Olin M, Badihi Y, Biesky M, Sprung CL, et al. A look into the nature and causes of human errors in the intensive care unit. Crit Care Med 1995;23:294–300.CrossRefPubMed Donchin Y, Gopher D, Olin M, Badihi Y, Biesky M, Sprung CL, et al. A look into the nature and causes of human errors in the intensive care unit. Crit Care Med 1995;23:294–300.CrossRefPubMed
19.
go back to reference Rogers DA, Regehr G, MacDonald J. A role for error training in surgical technical skill instruction and evaluation. Am J Surg 2002 Mar;183(3):242–5. Rogers DA, Regehr G, MacDonald J. A role for error training in surgical technical skill instruction and evaluation. Am J Surg 2002 Mar;183(3):242–5.
20.
go back to reference Michel P, Quenon JL, Sarasqueta AM de, Scemama O. Comparison of three methods for estimating rates of adverse events and rates of preventable adverse events in acute care hospitals. BMJ 2004;328: 199–202.PubMedCentralCrossRefPubMed Michel P, Quenon JL, Sarasqueta AM de, Scemama O. Comparison of three methods for estimating rates of adverse events and rates of preventable adverse events in acute care hospitals. BMJ 2004;328: 199–202.PubMedCentralCrossRefPubMed
21.
go back to reference Hayward RA, Hofer TP. Estimating hospital deaths due to medical errors: preventability is in the eye of the reviewer. JAMA 2001;286:415–20.CrossRefPubMed Hayward RA, Hofer TP. Estimating hospital deaths due to medical errors: preventability is in the eye of the reviewer. JAMA 2001;286:415–20.CrossRefPubMed
22.
go back to reference Henriksen K, Kaplan H. Hindsight bias, outcome knowledge and adaptive learning. Qual Saf Health Care. 2003;12(Suppl 2):ii46–50.PubMed Henriksen K, Kaplan H. Hindsight bias, outcome knowledge and adaptive learning. Qual Saf Health Care. 2003;12(Suppl 2):ii46–50.PubMed
23.
go back to reference Mant J. Process versus outcome indicators in the assessment of quality of health care. Int J Qual Health Care. 2001(Dec);13(6):475–80. Mant J. Process versus outcome indicators in the assessment of quality of health care. Int J Qual Health Care. 2001(Dec);13(6):475–80.
24.
go back to reference Bird SM, Cox D, Farewell VT, Goldstein H, Holt T, Smith PC. Performance indicators: good, bad, and ugly. J R Stat Soc (Series A) 2005;168:1–27. Bird SM, Cox D, Farewell VT, Goldstein H, Holt T, Smith PC. Performance indicators: good, bad, and ugly. J R Stat Soc (Series A) 2005;168:1–27.
25.
go back to reference Amalberti R, Auroy Y, Berwick D, Barach P. Five system barriers to achieving ultrasafe health care. Ann Intern Med 2005;142:756–64.CrossRefPubMed Amalberti R, Auroy Y, Berwick D, Barach P. Five system barriers to achieving ultrasafe health care. Ann Intern Med 2005;142:756–64.CrossRefPubMed
Metagegevens
Titel
5 De epidemiologie van medische fouten, medische: weten we wel wat we meten?
Auteur
R.W.M. Giard
Copyright
2006
Uitgeverij
Bohn Stafleu van Loghum
DOI
https://doi.org/10.1007/978-90-368-1100-2_5