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Sepsis: Medical errors in Poland

机译：败血症：波兰的医疗错误

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Health, safety and medical errors are currently the subject of worldwide discussion. The authors analysed medico-legal opinions trying to determine types of medical errors and their impact on the course of sepsis. The authors carried out a retrospective analysis of 66 medico-legal opinions issued by the Wroclaw Department of Forensic Medicine between 2004 and 2013 (at the request of the prosecutor or court) in cases examined for medical errors. Medical errors were confirmed in 55 of the 66 medico-legal opinions. The age of victims varied from 2 weeks to 68 years; 49 patients died. The analysis revealed medical errors committed by 113 health-care workers: 98 physicians, 8 nurses and 8 emergency medical dispatchers. In 33 cases, an error was made before hospitalisation. Hospital errors occurred in 35 victims. Diagnostic errors were discovered in 50 patients, including 46 cases of sepsis being incorrectly recognised and insufficient diagnoses in 37 cases. Therapeutic errors occurred in 37 victims, organisational errors in 9 and technical errors in 2. In addition to sepsis, 8 patients also had a severe concomitant disease and 8 had a chronic disease. In 45 cases, the authors observed glaring errors, which could incur criminal liability. There is an urgent need to introduce a system for reporting and analysing medical errors in Poland. The development and popularisation of standards for identifying and treating sepsis across basic medical professions is essential to improve patient safety and survival rates. Procedures should be introduced to prevent health-care workers from administering incorrect treatment in cases.
机译：健康，安全和医疗错误目前是全世界讨论的主题。作者分析了医学法律意见，试图确定医疗错误的类型及其对败血症过程的影响。作者对弗罗茨瓦夫法医学部在2004年至2013年期间（应检察官或法院的要求）发表的66项医学法律意见进行了回顾性分析，以检查是否存在医疗错误。在66项法律法律意见中，有55项确认了医疗错误。受害者的年龄从2周到68岁不等; 49例患者死亡。分析显示113名医护人员犯了医疗错误：98名医生，8名护士和8名紧急医疗调度员。在33例中，住院前犯了一个错误。 35名受害者中发生了医院错误。在50例患者中发现了诊断错误，其中46例败血症被错误识别，而37例诊断不足。治疗错误发生在37位受害者中，9位发生了组织错误，2位发生了技术错误。除了败血症外，8位患者还患有严重的伴随疾病，8位患者患有慢性疾病。在45个案例中，作者发现了明显的错误，可能导致刑事责任。迫切需要引入一种用于报告和分析波兰医疗错误的系统。跨基础医学专业鉴定和治疗脓毒症的标准的开发和普及对于提高患者的安全性和生存率至关重要。应采用程序以防止医护人员在案件中进行不正确的治疗。

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