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确定医疗保健"永远不会发生"事件列表以影响系统变化:系统性审查和叙事综合
Cara L Bowman1, Ria De Gorter1, Joanna Zaslow1
1Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, Ontario, Canada.
BMJ open quality
|June 26, 2023
概括
尽管存在各种框架,但患者安全从未发生事件 (NE) 仍在继续. 这次审查确定了最严重和可预防的NE,强调了错误的部位手术和错误的程序作为改善以提高患者安全的关键领域.
科学领域:
- 医疗保健的质量和安全
- 患者安全研究 患者安全研究
- 医疗错误分析 医学错误分析
背景情况:
- 从未发生的事件 (NE) 是严重的,可预防的患者安全事件,尽管存在许多干预框架,但仍然存在.
- 现有的NE框架在术语,事件分类和可预防性方面表现出多样性,阻碍了协作努力.
- 这一系统性审查解决了通过确定最严重和可预防的NE的统一方法的需要.
结论:
- 聚焦最严重和可预防的NE的综合清单对于有效的协作和从错误中学习至关重要.
- 对错误的身体部位或患者进行手术,以及错误的手术程序,成为符合这些标准的最关键的NE.
- 针对这些高影响力NE的有针对性的改进工作可以显著提高患者的安全性并减少伤害.
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