41例发生漏误诊的骨科医疗事故案例分析

41 Cases Analyses of Orthopedics Malpractices Accompanied with Missed Diagnosis or Diagnostic Errors

应用RCA方法对某市卫生局卫生监督所存档的41例骨科存在漏诊误诊的医疗事故报告书进行分析处理。对医疗事故的等级和责任程度、医疗事故在各级医院的分布、医疗事故的责任人职称分布、致伤原因、漏误诊损伤部位分布和医疗事故中患者的基本情况进行分析,得出统计结果,并针对结果进行讨论,提出建议。

The article applies RCA（ Root Cause Analysis）to analyze 41 orthopedics malpractices statements accompanied with missed diagnosis or diagnostic errors filed in Agency for Public Health Inspection of certain Municipal Health Bureau. We get some statistical analysis results in the grading of medical malpractices and duty levels,malpractices distributions in the hospital,doctors professional title distributions, venerated causes and injuries sites distributions, and the patients basic conditions. The last we give out reasonable suggestions based on the results.