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研究生:劉師秀
研究生(外文):Shih-Siou Liou
論文名稱:醫師主動告知醫療錯誤之阻礙因素及促進條件與其對告知及致歉意願之影響
論文名稱(外文):The Barrier Factors and Promotion Factors of Disclosing Medical Errors and Their Effects on Doctor’s Willingness to Disclose and Apologize for Medical Errors
指導教授:戴志展戴志展引用關係
學位類別:碩士
校院名稱:中國醫藥大學
系所名稱:醫務管理學研究所碩士班
學門:商業及管理學門
學類:醫管學類
論文種類:學術論文
論文出版年:2009
畢業學年度:97
語文別:中文
論文頁數:111
中文關鍵詞:主動告知醫療錯誤醫療糾紛醫病關係
外文關鍵詞:disclosuremedical errorsmedical disputedoctor-patient relationship
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目的:隨著美國醫學研究院(IOM)出版“To Err Is Human”,指出美國因可避免的醫療錯誤,造成每年超過一百萬人的醫療傷害後,不良事件(adverse events)與醫療錯誤(medical errors)被認為是主要健康照護問題。國外發展以主動告知(disclosure)來因應此問題,反觀國內對於醫療錯誤的因應僅著重於事前預防。而主動告知醫療錯誤的阻礙因素關係到此一政策是否能落實。研究目的在瞭解主動告知之阻礙因素及促進條件,進而瞭解兩者對主動告知及致歉意願之影響。
方法:本研究為橫斷性研究,針對不同層級的六家醫院發出自填式問卷,以了解醫師對於主動告知的阻礙因素、促進條件與告知及致歉意願。回收有效問卷423份,回收率為82.9%。
結果:研究發現最主要之主動告知阻礙因素為「擔心被告」,最能促進告知之條件為「病人可理性溝通時」。告知意願中,86.5%會告知輕微醫療錯誤,69.7%會告知嚴重醫療錯誤,而致歉意願中,86.6%會致歉輕微醫療錯誤,79.0%會致歉嚴重醫療錯誤。在控制其他變項後之階層邏輯斯分析結果,影響主動告知及致歉輕微醫療錯誤意願之共同因素為:「擔心自己名聲受損」、「醫療錯誤嚴重度高時」、「病人社經地位高時」、「病人教育程度高時」、「與病人及家屬熟悉度高時」、「病人及家屬可理性溝通時」及「病人及家屬對病情了解度高時」。影響主動告知及致歉嚴重醫療錯誤意願之共同因素,除了上述因素之外再加上:「擔心被告」、「擔心醫病關係惡化」、「擔心病人不理性」、「病人疾病嚴重度高時」、「病人年齡高時」。
結論:本研究建議開放討論的工作環境可鼓勵醫師積極面對醫療錯誤,且將主動告知醫療錯誤納入醫師訓練之一環以促進告知意願。
Objective: According to “To Err Is Human” published by IOM in 2000, there were more than 1 million medical injuries happened in United States. Most of that could be avoided. The adverse events and medical errors are considered as the major problems in healthcare system. In Taiwan, efforts are focused on preventing medical errors in advance. However, some countries introduce “disclosure” to solve the problems of adverse events and medical errors; Barriers of disclosure will play an important role in the successfulness of the new policy. This objective of this research is to explore the barriers and the promotion factors of doctor’s disclosing medical error in Taiwan. Also we wish to know what kind of factors will affect doctor’s disclosure and apology for that.
Methods: This research is cross-sectional survey. We provide the self-administrated questionnaire to 510 doctors in six hospitals. 423 eligible questionnaires were received. The response rate is 82.9%.
Result: “Concerning to be sued” is the major barrier factor of disclosure. “When patient is reasonable to communicate” is the major promotion factor of disclosure. 86.5% respondents are willing to disclose minor medical error; 69.7% respondents are willing to disclose serious medical error. 86.6% respondents are willing to apologize for minor medical error; 79% respondents are willing to apologize for serious medical error. From hierarchical logistic test, “Concerning of professional reputation”, “Severity of medical error”, “Patient with higher social-economical status”, “Patient with higher education background”, “Doctor knowing patient or his/her family well”, “Patient and his/her family are reasonable to communication” and “Patient and his/her family realizing patient’s condition very well” are the common factors to affect doctor’s disclosure and apology for minor medical errors. In addition to above factors, “Concerning to be sued”, “Concerning impact on doctor-patient relationship”, “Concerning patient having unreasonable response”, “Patient with serious condition” and “Old aged patient” are the common factors to affect the doctor’s disclosure and apology for serious medical error.
Conclusion: This research suggests that an open discussion working environment may encourage doctors face medical error more positively. Education programs may be needed for medical doctors to improve their willingness to disclose and apologize for medical errors.
目錄
中文摘要 I
Abstract II
致謝 IV
目錄 V
表目錄 VII
圖目錄 X
第一章 緒 論 1
第一節 研究背景與動機 1
第二節 研究目的 5
第二章 文獻探討 6
第一節 醫療錯誤與不良事件 6
第二節 主動告知醫療錯誤 16
第三節 主動告知效益 22
第四節 主動告知之阻礙因素與促進條件 24
第五節 國外主動告知醫療錯誤之現況 29
第六節 文獻小結 32
第三章 研究方法 33
第一節 研究架構 33
第二節 研究假設 35
第三節 研究對象與進行方式 36
第四節 研究工具 37
第五節 變項操作型定義 40
第六節 分析方法 42
第四章 研究結果 43
第一節 描述性分析 43
第二節 雙變項分析 49
第三節 多變項分析 69
第五章 討論 87
第一節 主動告知醫療錯誤之阻礙因素 87
第二節 主動告知醫療錯誤之促進條件 90
第三節 主動告知及致歉醫療錯誤之意願 93
第四節 主動告知阻礙因素與促進條件對告知及致歉意願之影響 95
第六章 結論與建議 96
第一節 結論 96
第二節 建議 100
第三節 研究限制 102
參考文獻 103
附錄 109
表目錄
表2-1 醫療錯誤與不良事件相關名詞定義 10
表2-2 醫療錯誤與不良事件之國際間相關實証研究結果 15
表2-3 主動告知的8個W 21
表2-4 主動告知效益 23
表2-5 主動告知阻礙分類表 26
表2-6 病人對醫療錯誤負面反應之因素 28
表2-7 影響病人對訴訟反應之因素 28
表2-8 影響病人對主動告知反應之因素 28
表3-1 問卷發放比例與份數 36
表3-2 信度分析結果 39
表3-3 研究變項及操作型定義 40
表4-1 各家醫院問卷發放及回收情形 43
表4-2 回收樣本基本資料 44
表4-3 基本特性在內、外科間差異情形 45
表4-4 基本特性在醫院間差異情形 45
表4-5 主動告知醫療錯誤阻礙之平均值及標準差 47
表4-6 主動告知醫療錯誤促進條件之平均值及標準差 48
表4-7 主動告知及致歉醫療錯誤意願之個數與百分比 48
表4-8 主動告知醫療錯誤阻礙之相關 56
表4-9 主動告知醫療錯誤促進條件之相關 57
表4-10 主動告知醫療錯誤促進條件之相關(變項合併後) 58
表4-11 主動告知醫療錯誤阻礙因素於醫師經驗上之差異 59
表4-12 主動告知醫療錯誤阻礙因素於不同性別下之差異及有無宗教信仰下之差異 61
表4-13 主動告知醫療錯誤阻礙因素於內、外科間之差異及住院、主治間之差異 60
表4-14 主動告知醫療錯誤阻礙因素於醫師所屬醫院特質上之差異 62
表4-15 主動告知醫療錯誤促進條件於醫師經驗上之差異 63
表4-16 主動告知醫療錯誤促進條件於不同性別下之差異及有無宗教信仰下之差異 64
表4-17 主動告知醫療錯誤促進條件於內、外科間之差異及住院、主治間之差異 65
表4-18 主動告知醫療錯誤促進條件於醫師所屬醫院特質上之差異 66
表4-19 主動告知及致歉醫療錯誤於控制變項上之卡方分析 67
表4-20 主動告知醫療錯誤之阻礙因素及促進條件與主動告知及致歉意願之簡單邏輯斯分析 68
表4-21 主動告知輕微醫療錯誤之階層邏輯斯分析 72
表4-22 擔心被告對主動告知輕微醫療錯誤之階層邏輯斯分析 73
表4-23 擔心執照被吊銷對主動告知輕微醫療錯誤之階層邏輯斯分析 74
表4-24 擔心自己名聲受損對主動告知輕微醫療錯誤之階層邏輯斯分析 75
表4-25 擔心病患對我失去信心對主動告知輕微醫療錯誤之階層邏輯斯分析 76
表4-26 主動告知嚴重醫療錯誤之階層邏輯斯分析 77
表4-27 主動致歉輕微醫療錯誤之階層邏輯斯分析 78
表4-28 擔心自己名聲受損對主動致歉輕微醫療錯誤之階層邏輯斯分析 79
表4-29 擔心醫病關係惡化對主動致歉輕微醫療錯誤之階層邏輯斯分析 80
表4-30 病人疾病嚴重度高時對主動致歉輕微醫療錯誤之階層邏輯斯分析 81
表4-31 醫療錯誤嚴重度高時對主動致歉輕微醫療錯誤之階層邏輯斯分析 82
表4-32 病人年齡高時對主動致歉輕微醫療錯誤之階層邏輯斯分析 83
表4-33 主動致歉嚴重醫療錯誤之階層邏輯斯分析 84
表4-34 擔心病患對我失去信心對主動致歉嚴重醫療錯誤之階層邏輯斯分析 85
表4-35 各變項加入控制變項後影響主動告知及致歉意願之邏輯斯分析 86
圖目錄
圖2-1 醫療錯誤與不良事件關係圖 12
圖2-2 醫療錯誤與不良事件之國際間相關實証研究數據圖 15
圖3-1 研究架構 34
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