Fehler und kritische Ereignisse in der Palliativmedizin – Etablierung eines anonymen Fehlermeldesystems

 

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Zusammenfassung

Hintergrund: Das anonyme Melden von Fehlern und Beinahe-Fehlern im Rahmen von Critical-Incident-Reporting-Systemen hat sich in der Medizin als geeignetes Instrument zur Identifikation von Fehlern und zur systematischen Fehlervermeidung erwiesen. Für die Palliativmedizin wurde im Mai 2011 ein eigenes, öffentlich zugängliches CIRS eingeführt. Ob die Analyse gemeldeter Fälle dazu beitragen kann, die Arten und Bereiche sowie Ursachen und Konsequenzen von Fehlern in der Palliativ Care besser zu verstehen, war Fragestellung der ersten Auswertungen.

Methoden: 1.) Im Rahmen einer Umfrage unter palliativmedizinischen Einrichtungen in Bayern wurden 2010 erstmals quantitative und qualitative Daten zum Thema Fehler in Palliative Care gesammelt. Aus den qualitativen Daten wurden mittels der Inhaltsanalyse nach Mayring Kategorien für Bereiche/Arten und Konsequenzen von Fehlern in der Palliative Care ermittelt und 2.) zwei der ersten im neu etablierten, anonymen Meldeportal „CIRS-Palliativ“ gemeldeten Fallberichte gegenübergestellt.

Ergebnisse: Die Rücklaufquote der Umfrage lag bei 42 % (n = 70); zwei Drittel der Antwortenden hatten Freitext-Angaben zu einem typischen Fehler in Palliative Care gemacht. Bereiche von Fehlern waren Medikation (v. a. Schmerztherapie) und Kommunikation sowie palliative Sedierung, Organisation und System, Therapieziel, End-of-Life Care und Anamnese. Die bisher in CIRS-Palliativ gemeldeten Ereignisse können weitgehend den ersten beiden Kategorien zugeordnet werden.

Diskussion: Die Anzahl und die Inhalte der Freitexte unserer Umfrage als auch die Analyse der ersten gemeldeten Fälle bestätigen den Bedarf eines CIRS-Palliativ. Dieses soll zukünftig zum offenen Austausch über Fehler und Beinahe-Fehler in Palliative Care anregen und so die Möglichkeit zur Bewältigung von Fehlern und zur Erarbeitung von konkreten Strategien der Fehlervermeidung bieten.

Abstract

Background: Anonymous reporting systems for errors and near-misses in medicine have been shown to be useful for identification and systematic prevention of errors. Since May 2011 a critical incident reporting system for palliative care is open for the public. If the analysis of reported cases can be helpful for a better understanding of kinds or areas, causes and consequences of errors in palliative care should be proven by first evaluations.

Methods: 1) In 2010 a survey of palliative care professionals in Bavaria gained first quantitative and qualitative data about errors in palliative care. According to the method of content analysis by Mayring qualitative data were analyzed and categories for kind/area and consequences of errors in palliative care were extracted and 2) compared to two of the reported cases from the newly establishes anonymous reporting system.

Results: Rate of return of our survey was 42 % (n = 70), 2 third of all respondents showed information about a typical error in palliative care in the corresponding free text field. As areas of errors medication (especially pain treatment) and communication, palliative sedation, organisation and system, treatment goal, end-of-life care and patient history could be evaluated. Both of the 2 compared case report from CIRS-Palliativ can be assigned to the first 2 categories.

Discussion: Number and content of the data reported in the free text fields of our survey even as analysis of the first reported cases confirmed the need for a CIRS-palliative. This system is thought to trigger further discussion about errors and near-misses and to present a possible tool for handling and future prevention of errors in palliative care.

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