Using Medical Emergency Teams to detect preventable adverse events 英文参考文献.docVIP

Available online /content/13/4/R126 Research Open Access Vol 13 No 4 Using Medical Emergency Teams to detect preventable adverse events Akshai Iyengar1, Alan Baxter2 and Alan J Forster1,3 1Department of Medicine, Faculty of Medicine, University of Ottawa, 451 Smyth Road, Ottawa, ON, K1H 8M5, Canada 2Department of Anaesthesia, Faculty of Medicine, University of Ottawa, 451 Smyth Road, Ottawa, ON, K1H 8M5, Canada 3Clinical Epidemiology Program, Ottawa Hospital Research Institute, 725 Parkdale Avenue, Ottawa, ON, K1Y 4E9, Canada Corresponding author: Alan J Forster, aforster@ohri.ca Received: 12 Feb 2009 Revisions requested: 17 Apr 2009 Revisions received: 10 Jun 2009 Accepted: 30 Jul 2009 Published: 30 Jul 2009 Critical Care 2009, 13:R126 (doi:10.1186/cc7983) This article is online at: /content/13/4/R126 ? 2009 Iyengar et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Introduction Medical Emergency Teams (METs), also known as Rapid Response Teams, are recommended as a patient safety measure. A potential benefit of implementing an MET is the capacity to systematically assess preventable adverse events, which are defined as poor outcomes caused by errors or system design flaws. We describe how we used MET calls to Results We captured information on all 65 MET calls occurring during the study period. Of these, 16 (24%, 95% confidence interval [CI] 16%–36%) were felt to be preventable adverse events. The most common cause of the preventable adverse events was error in providing appropriate therapy despite an accurate diagnosis. One service accounted for a disproportionate number of preventable adverse events (n = 5, [31%, 95% CI 14%–56%]). systematically identify preventable adver