Aus Fehlschlägen lernen – Implikationen für die Pneumologie und Intensivmedizin: Ein konzeptionelles Review

Zusammenfassung

Die klinischen, gesellschaftlichen und ökonomischen Auswirkungen von medizinischen Fehlschlägen sind immens – gerade in der Pneumologie und Intensivmedizin durch besonders gravierende Ereignisse bei respiratorischer Insuffizienz, Beatmungstherapie oder Medikamentengaben. Trotz der offensichtlichen Notwendigkeit, aus (Beinahe-)Fehlschlägen zu lernen, bleibt die Umsetzung eine Rarität. Ziel dieses konzeptionellen Reviews ist es daher, Grundlagen der Terminologie, relevante Hinderungsgründe sowie mögliche Strategien aufzuzeigen, um systematisch und effektiv aus Fehlschlägen zu lernen. Basierend auf einer elektronischen Literaturrecherche (Stand: Juni 2013) unter Einbeziehung von Medline via PubMed, EMBASE, ERIC sowie Google Scholar wurden als wesentliche Hindernisgründe identifiziert: persönliche Schuldzuweisungen und das konsekutive Verheimlichen von (Beinahe-)Fehlschlägen, fehlende Analysen auf Systemebene (vs. Individualversagen) sowie (ökonomische) Fehlanreize. An wichtigen Strategien wurden identifiziert: Bedeutung des Führungsstils mit Schaffung sicherer Rahmenbedingungen, offene Berichterstattung, tragfähige Feedbackkultur, Detektionsmechanismen (z. B. „Trigger“-Werkzeuge) sowie Analyse- und Diskussionsverfahren (z. B. Zweischleifen-Lernen). Die Gründe für das Auftreten von (Beinahe-)Fehlschlägen betreffen alle Berufsgruppen im Gesundheitswesen und liegen in menschlichen, strukturellen und organisatorischen Problemfeldern. Analysen und Lösungsansätze sollten stets all diese Aspekte berücksichtigen und neben dem Individuum v. a. auch die Ebene des Systems betrachten.

Abstract

The clinical, social and economical impact of failure in medicine [i. e., adverse health care events (AHCE)] is overwhelming. Respiratory and intensive care medicine are strongly relevant to AHCE, particularly in cases associated with respiratory failure, mechanical ventilation and pharmacotherapy. In spite of the obvious necessity to learn from AHCE, its realisation in health-care organisations is still rare. This conceptual review therefore aims to (i) clarify the most relevant terminology, (ii) identify obstacles related to this health-care topic, and (iii) present possible strategies for solving the problems, thereby enabling respiratory and intensive care medicine to systematically and effectively learn from failure. A review of the literature (effective as of June 2013) derived from the electronic databases Medline via PubMed, EMBASE, ERIC and Google Scholar identified the following relevant obstacles (ii): a so-called blame culture associated with concealing failure, missing system analyses (vs. individual breakdown), and (economically) misdirected incentives. Possible strategies to overcome these obstacles (iii) include acknowledging the importance of leadership, a safe environment, open reporting, an effective feedback culture, and detection (e. g., trigger-tools), analysis and discussion (e. g., double loop learning) of failure. The underlying reasons for the occurrence of AHCE are based on structural, organisational and human shortcomings, and affect all categories of caregivers. Approaches to solving the problem should therefore focus primarily on the entire system, rather than on the individual alone.

• Literatur

• 1 Kohn LT, Corrigan JM, Donaldson MS eds. To Err Is Human: Building a Safer Health System. The National Academies Press; 2000 Im Internet: http://www.nap.edu/openbook.php?record_id=9728 Stand: 03.06.2013
• 2 Vincent C. Understanding and responding to adverse events. N Engl J Med 2003; 348: 1051-1056
• 3 Zhan C, Miller MR. Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization. J Am Med Assoc 2003; 290: 1868-1874
• 4 Vlayen A, Verelst S, Bekkering GE et al. Incidence and preventability of adverse events requiring intensive care admission: a systematic review. J Eval Clin Pract 2012; 18: 485-497
• 5 Stieglitz S, George S, Priegnitz C et al. Life-threatening Events in Respiratory Medicine: Misconnections of Invasive and Non-invasive Ventilators and Interfaces. Pneumologie 2013; 67: 228-232
• 6 Frey B, Kehrer B, Losa M et al. Comprehensive critical incident monitoring in a neonatal-pediatric intensive care unit: experience with the system approach. Intensive Care Med 2000; 26: 69-74
• 7 Bracco D, Favre JB, Bissonnette B et al. Human errors in a multidisciplinary intensive care unit: a 1-year prospective study. Intensive Care Med 2001; 27: 137-145
• 8 Thomas EJ, Studdert DM, Burstin HR et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care 2000; 38: 261-271
• 9 Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review. BMJ 2001; 322: 517-519
• 10 Wilson RM, Runciman WB, Gibberd RW et al. The Quality in Australian Health Care Study. Med J Aust 1995; 163: 458-471
• 11 Brennan TA, Leape LL, Laird NM 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: 370-376
• 12 Chaboyer W, Thalib L, Foster M et al. Predictors of adverse events in patients after discharge from the intensive care unit. Am J Crit Care 2008; 17: 255-263
• 13 Donchin Y, Gopher D, Olin M et al. A look into the nature and causes of human errors in the intensive care unit. Crit Care Med 1995; 23: 294-300
• 14 Abramson NS, Wald KS, Grenvik AN et al. Adverse occurrences in intensive care units. J Am Med Assoc 1980; 244: 1582-1584
• 15 Wright D, Mackenzie SJ, Buchan I et al. Critical incidents in the intensive therapy unit. Lancet 1991; 338: 676-678
• 16 Rosenberg AL, Watts C. Patients readmitted to ICUs* : a systematic review of risk factors and outcomes. Chest 2000; 118: 492-502
• 17 Metnitz PGH, Fieux F, Jordan B et al. Critically ill patients readmitted to intensive care units--lessons to learn?. Intensive Care Med 2003; 29: 241-248
• 18 Bates DW, Leape LL, Petrycki S. Incidence and preventability of adverse drug events in hospitalized adults. J Gen Intern Med 1993; 8: 289-294
• 19 Capuzzo M, Nawfal I, Campi M et al. Reporting of unintended events in an intensive care unit: comparison between staff and observer. BMC Emerg Med 2005; 5: 3
• 20 Leape LL, Brennan TA, Laird N et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med 1991; 324: 377-384
• 21 Kopp BJ, Erstad BL, Allen ME et al. Medication errors and adverse drug events in an intensive care unit: direct observation approach for detection. Crit Care Med 2006; 34: 415-425
• 22 Welters ID, Gibson J, Mogk M et al. Major sources of critical incidents in intensive care. Crit Care 2011; 15: R232
• 23 Edmondson AC. Learning from Mistakes is Easier Said Than Done: Group and Organizational Influences on the Detection and Correction of Human Error. J Appl Behav Sci 1996; 32: 5-28
• 24 Reinertsen JL. Let’s talk about error. BMJ 2000; 320: 730
• 25 Edmondson AC. Learning from failure in health care: frequent opportunities, pervasive barriers. Qual Saf Health Care 2004; 13 (Suppl. 02) ii3-9
• 26 Stoller JK. Implementing change in respiratory care. Respir Care 2010; 55: 749-757
• 27 Anders ME, Evans DP. Comparison of PubMed and Google Scholar literature searches. Respir Care 2010; 55: 578-583
• 28 Nourbakhsh E, Nugent R, Wang H et al. Medical literature searches: a comparison of PubMed and Google Scholar. Heal Inf Libr J 2012; 29: 214-222
• 29 Le Dévic N. Council of Europe recommendation and glossary on patient and medication safety: CPME Info 86-2006. Im Internet: http://cpme.dyndns.org:591/database/2006/Info.2006-086.enonly.pdf Stand: 03.06.2013
• 30 Sheikh A, Hurwitz B. Setting up a database of medical error in general practice: conceptual and methodological considerations. Br J Gen Pract 2001; 51: 57-60
• 31 Vincent C, Stanhope N, Crowley-Murphy M. Reasons for not reporting adverse incidents: an empirical study. J Eval Clin Pract 1999; 5: 13-21
• 32 Edmondson AC, Schein EH. Teaming: How Organizations Learn, Innovate, and Compete in the Knowledge Economy. 01. Aufl. San Francisco: John Wiley & Sons; 2012
• 33 Resar RK, Rozich JD, Classen D. Methodology and rationale for the measurement of harm with trigger tools. Qual Saf Health Care 2003; 12 (Suppl. 02) ii39-45
• 34 Aspden P, Corrigan JM, Wolcott J, Erickson SM eds. Patient Safety: Achieving a New Standard for Care. The National Academies Press; 2004 Im Internet: http://www.nap.edu/openbook.php?record_id=10863 Stand: 03.06.2013
• 35 Boyle D, O’Connell D, Platt FW et al. Disclosing errors and adverse events in the intensive care unit. Crit Care Med 2006; 34: 1532-1537
• 36 Cannon MD, Edmondson AC. Failing to Learn and Learning to Fail (Intelligently). Long Range Plann 2005; 38: 299-319
• 37 Reason JT, Carthey J, de Leval MR. Diagnosing “vulnerable system syndrome”: an essential prerequisite to effective risk management. Qual Heal Care 2001; 10 (Suppl. 02) ii21-25
• 38 Nottingham J. Medical errors. Perhaps blame-free culture is needed in NHS to reduce errors. BMJ 2001; 322: 1422
• 39 Turton C. Medical errors. Media tend to link error with blame. BMJ 2001; 322: 1422
• 40 Reason J. Human error: models and management. BMJ 2000; 320: 768-770
• 41 Edmondson AC. Strategies of learning from failure. Harv Bus Rev 2011; 89: 48-55, 137
• 42 Perrow C. Normal Accidents: Living with High-Risk Technologies. Updated. 01. Aufl. Chichester: Princeton University Press; 1999
• 43 Vincent C, Taylor-Adams S, Chapman EJ et al. How to investigate and analyse clinical incidents: clinical risk unit and association of litigation and risk management protocol. BMJ 2000; 320: 777-781
• 44 Garvin DA, Edmondson AC, Gino F. Is yours a learning organization?. Harv Bus Rev 2008; 86: 109-116, 134
• 45 Milligan F, Bird D. Adverse health-care events: Part 4. Challenge of a blame-free culture. Prof Nurse 2003; 18: 705-709
• 46 Tucker AL, Nembhard IM, Edmondson AC. Implementing New Practices: An Empirical Study of Organizational Learning in Hospital Intensive Care Units. Manag Sci 2007; 53: 894-907
• 47 Wise JA, Hopkin VD, Stager P eds. Verification and Validation of Complex Systems: Human Factors Issues. 01. Aufl. New York, Heidelberg: Springer; 2010: 402
• 48 Edmondson AC. The competitive imperative of learning. Harv Bus Rev 2008; 86: 60-67, 160
• 49 Bird D, Milligan F. Adverse health-care events: Part 2. Incident reporting systems. Prof Nurse 2003; 18: 572-575
• 50 Bird D, Milligan F. Adverse health-care events: Part 3. Learning the lessons. Prof Nurse 2003; 18: 621-625
• 51 Ramani S, Krackov SK. Twelve tips for giving feedback effectively in the clinical environment. Med Teach 2012; 34: 787-791
• 52 Edmondson AC. Framing for Learning: Lessons in Successful Technology Implementation. Calif Manage Rev 2003; 45: 34-54
• 53 Shortell SM, Zimmerman JE, Rousseau DM et al. The performance of intensive care units: does good management make a difference?. Med Care 1994; 32: 508-525
• 54 Curtis JR, Cook DJ, Wall RJ et al. Intensive care unit quality improvement: a “how-to” guide for the interdisciplinary team. Crit Care Med 2006; 34: 211-218
• 55 Classen D, Pestotnik S, Evans R et al. Computerized surveillance of adverse drug events in hospital patients*. Qual Saf Health Care 2005; 14: 221-226
• 56 De Feijter JM, de Grave WS, Muijtjens AM et al. A comprehensive overview of medical error in hospitals using incident-reporting systems, patient complaints and chart review of inpatient deaths. Plos One 2012; 7: e31125
• 57 Tucker AL, Edmondson AC. Why Hospitals Don’t Learn from Failures: Organizational and Psychological Dynamics that Inhibit System Change. Calif Manage Rev 2003; 45: 55-72
• 58 Cullen DJ, Sweitzer BJ, Bates DW et al. Preventable adverse drug events in hospitalized patients: a comparative study of intensive care and general care units. Crit Care Med 1997; 25: 1289-1297
• 59 Rozich JD, Haraden CR, Resar RK. Adverse drug event trigger tool: a practical methodology for measuring medication related harm. Qual Saf Health Care 2003; 12: 194-200
• 60 Thomas EJ, Petersen LA. Measuring errors and adverse events in health care. J Gen Intern Med 2003; 18: 61-67
• 61 Classen DC, Lloyd RC, Provost L et al. Development and Evaluation of the Institute for Healthcare Improvement Global Trigger Tool. J Patient Saf 2008; 4: 169-177
• 62 Sari AB-A, Sheldon TA, Cracknell A et al. Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review. BMJ 2007; 334: 79
• 63 Pronovost PJ, Holzmueller CG, Martinez E et al. A practical tool to learn from defects in patient care. Jt Comm J Qual Patient Saf 2006; 32: 102-108
• 64 McGloin H, Adam SK, Singer M. Unexpected deaths and referrals to intensive care of patients on general wards. Are some cases potentially avoidable?. J R Coll Physicians Lond 1999; 33: 255-259
• 65 McGaughey J, Alderdice F, Fowler R et al. Outreach and Early Warning Systems (EWS) for the prevention of intensive care admission and death of critically ill adult patients on general hospital wards. Cochrane Database Syst Rev 2007; 3 CD005529
• 66 Stewart S, Voss DW. A study of unplanned readmissions to a coronary care unit. Heart Lung J Crit Care 1997; 26: 196-203
• 67 Campbell WB. Surgical morbidity and mortality meetings. Ann R Coll Surg Engl 1988; 70: 363-365
• 68 Cheney FW, Posner K, Caplan RA et al. Standard of care and anesthesia liability. J Am Med Assoc 1989; 261: 1599-1603
• 69 MDS – Medizinischer Dienst des Spitzenverbandes Bund der Krankenkassen e.V. Jahresstatistik 2011 zur Behandlungsfehler-Begutachtung der MDK-Gemeinschaft. Im Internet: http://www.mdk.de/media/pdf/Bericht_2011_Behandlungsfehler-Begutachtung_MDK-Gemeinschaft.pdf Stand: 03.06.2013
• 70 MDS – Medizinischer Dienst des Spitzenverbandes Bund der Krankenkassen e.V. Jahresstatistik 2012 zur Behandlungsfehler-Begutachtung der MDK-Gemeinschaft. Im Internet: http://www.mdk.de/media/pdf/8_-_Bericht_BHF-Begutachtung_2012_final.pdf Stand: 03.06.2013
• 71 Jena AB, Seabury S, Lakdawalla D et al. Malpractice risk according to physician specialty. N Engl J Med 2011; 365: 629-636
• 72 Classen DC, Pestotnik SL, Evans RS et al. Computerized surveillance of adverse drug events in hospital patients. J Am Med Assoc 1991; 266: 2847-2851
• 73 Bates DW. Using information technology to reduce rates of medication errors in hospitals. BMJ 2000; 320: 788-791
• 74 Bundesärztekammer. Curriculum Ärztliches Peer Review. Im Internet: http://www.bundesaerztekammer.de/page.asp?his=1.120.1116.9069 Stand: 03.06.2013
• 75 Hawryluck LA, Espin SL, Garwood KC et al. Pulling together and pushing apart: tides of tension in the ICU team. Acad Med 2002; 77: 73-76
• 76 Lingard L, Espin S, Evans C et al. The rules of the game: interprofessional collaboration on the intensive care unit team. Crit Care 2004; 8: R403-408
• 77 Henneman EA, Gawlinski A. A “near-miss” model for describing the nurse’s role in the recovery of medical errors. J Prof Nurs 2004; 20: 196-201
• 78 Milligan F, Bird D. Adverse health-care events: Part 1. The nature of the problem. Prof Nurse 2003; 18: 502-505
• 79 Sherman H, Castro G, Fletcher M et al. Towards an International Classification for Patient Safety: the conceptual framework. Int J Qual Heal Care 2009; 21: 2-8
• 80 Brasel KJ, Layde PM, Hargarten S. Evaluation of error in medicine: application of a public health model. Acad Emerg Med 2000; 7: 1298-1302
• 81 Bennett BS, Lipman AG. Comparative study of prospective surveillance and voluntary reporting in determining the incidence of adverse drug reactions. Am J Hosp Pharm 1977; 34: 931-936
• 82 Haddon Jr W. A logical framework for categorizing highway safety phenomena and activity. J Trauma 1972; 12: 193-207
• 83 Kasenda B, von Elm EB, You J et al. Learning from failure--rationale and design for a study about discontinuation of randomized trials (DISCO study). BMC Med Res Methodol 2012; 12: 131
• 84 Gino F, Pisano GP. Why leaders don’t learn from success. Harv Bus Rev 2011; 89: 68-74, 137
• 85 Beckett S. Worstward Ho. 04. Aufl. London: John Calder; 1999