失误病例网络数据库的建立及102例失误病例总结

Establishment of internet-based online database of orthopedic failure surgery and summary of 102 cases

目的建立失误病例网络数据库，共享失误病例，吸取教训，促进临床工作的开展，避免或减少医源性失误的发生。方法建立网络失误病例数据库，由所有中华骨科网骨科医生用户自行上传所遇到的临床失误病例。统计此数据库自2006年8月25日到2007年12月31日运行1年余所收集的失误病例。结果典型病例102份，其中治疗过程中存在明显失误的病例：内固定导致失误87例、外固定导致失误5例、保守治疗导致失误7例、关节置换失误3例。按照医方、患方和不确定因素三大方面总结：涉及到医方治疗过程中的失误67例，无确定因素导致的失误31例，患者方面因素导致的治疗失误4例。失误病例资料来源：一级医疗机构失误病例6例、二级医疗机构失误病例76例、三级医疗机构失误病例20例。结论失误病例网络数据库的建立有助于收集积累不同医疗单位所发生的失误病例，供临床骨科医生学习和避免类似失误的发生。临床新技术新业务的开展（新型内固定材料的使用，关节及脊柱手术的开展等）应该经过良好的培训及认证。

Objective To summarize the experience of internet-based online database of orthopedic failure surgery. Methods Based on the OrthoChina project, a sub-database for orthopedic failure surgery was established, open to the orthopedic surgeons for viewing, uploading, and sharing the experience. All cases were uploaded by the orthopedic surgeon users registering in the OrthoChina project from 25 August 2006 to 31 December 2007 were summarized. Results 102 failure surgery cases had been uploaded in the database, in which 87 were caused by internal instrumentation, 5 by external fixation, 7 by conservative treatment, and 3 by hip arthroplasty. Sixty-seven cases involved the poor performance of the orthopedic surgeons, 4 involved the patients related, and the causes of the other 31 cases remained unknown. Six failure cases occurred in class 1 hospitals, 76 cases in class 2 hospitals, and 20 in class 3 hospitals, Conclusion Intemet based online database for orthopedic failure surgery helps collect the failed orthopedic treatment from different surgeons and different hospitals. Sharing such experience helps the orthopedic surgeons avoid such therapeutic errors and improve their work. Qualified training and certification are necessary for the application of new techniques and implants.