Risikomanagement in pädiatrischen Kliniken

ZusammenfassungJede Behandlung von Patienten beinhaltet das Risiko von Fehlern, die potenziell eine Gefahr für deren Gesundheit darstellen. Ein zentrales Instrument der Fehlererkennung und -vermeidung sind anonyme Meldesysteme für kritische Ereignisse (CIRS: „critical incident reporting system“, CI: Beinaheschäden und Fehler). In einer multizentrischen Studie wurden ein CIRS in den klinischen Alltag von 12 norddeutschen Kinderkliniken implementiert und über 24 Monate zentral eine Sammlung und Analyse aller eingehenden Fehlerberichte vorgenommen. Aus den 1299 Berichten wurden 1829 Risikokonstellationen extrahiert. Die häufigsten waren Medikationsfehler mit 35%, Verfehlung von Standards mit 24% und Risiken durch Dokumentationsfehler mit 15%. Die Daten zeigen repräsentativ für die stationäre Pädiatrie typische Risiken, ohne die Inzidenz solcher Fehler messen zu können. Aus den Berichten wurden Präventionsmaßnahmen für die beteiligten Kliniken abgeleitet und Empfehlungen für die Fehlervermeidung formuliert. Die Ergebnisse zeigen, dass ein Fehlermeldesystem in Kliniken in Deutschland mit signifikantem Benefit für die Sicherheit der Patienten eingeführt und erfolgreich in den Alltag einer Klinik integriert werden kann.AbstractIatrogenic injuries as a consequence of medical errors are a serious problem in medicine. Critical incident reporting systems (CIRS) aim to reduce these errors and near-misses. By collecting data to identify and analyse risk factors, prevention strategies can be planned and instituted. In a multicentre study in 12 paediatric hospitals in northern Germany, CIRS were implemented, and data on the type and characteristics of errors and near-misses were collected. From 1,299 reports, 1,829 risk constellations were identified. The majority were attributed to medication errors (35%), failure to follow standards (24%), and errors due to incorrect documentation (15%). Our data show typical risks for paediatric hospital patients without measuring the real incidence of medical errors and near-misses. Based on the reports, risk management strategies were developed to reduce the risk of similar errors and adverse events. The study also shows that CIRS are realizable in paediatric wards and that they help improve patient safety.

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