让我们到TWISST;计划,模拟,研究和行动
1From the Department of Pediatrics, Division of Pediatric Critical Care, Children's Healthcare of Atlanta, Atlanta, Ga.
Pediatric quality & safety
|July 12, 2023
概括
翻译工作整合模拟和系统测试 (TWISST) 是一种新的工具,可以识别和修复系统错误. 这种基于模拟的方法通过将系统改进与培训相结合,改善了患者安全和临床工作流程.
科学领域:
- 医疗保健系统工程 系统工程
- 患者安全研究 患者安全研究
- 基于模拟的教育
背景情况:
- 医疗保健系统在识别和减轻错误方面面临复杂的挑战.
- 传统的错误检测方法可能无法完全解决工作系统中的潜在安全威胁 (LST).
- 模拟为系统分析和改进提供了一种强大的模式.
研究的目的:
- 引入和评估翻译工作整合模拟和系统测试 (TWISST) 方法.
- 为了证明TWISST在诊断和纠正LST和过程低效率方面的能力.
- 强调基于模拟的临床系统测试与基于模拟的培训 (SbT) 的整合.
主要方法:
- TWISST方法采用了代的计划-模拟-研究-行动循环.
- 它整合了模拟场景,汇报 (总结,定,促进,探索,引起),以及故障模式和效果分析.
- 前线团队通过SbT积极识别低效率,测试解决方案和硬线改进.
主要成果:
- TWISST确定了41个LST,主要与资源/设备/供应 (44%) 和患者安全 (34%) 相关.
- 工作系统改进解决了27个LST,其中16个LST通过消除浪费或优化环境来减轻.
- 针对44%的LST的系统更改造成了每次创伤区11.000美元的成本.
结论:
- TWISST是一种创新的策略,用于在医疗保健系统中有效诊断和纠正LST.
- 该方法独特地将强大的工作系统改进与综合培训相结合.
- TWISST有助于将系统改进纳入临床实践,改善工作流程和安全性.
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