多方面的干预措施,以改善重症监护病房的患者安全事件报告
Elaine M Griffeth1, Ognjen Gajic2, Nicole Schueler3
1From the Department of Surgery.
Journal of patient safety
|July 19, 2023
概括
一项质量改善干预措施成功提高了重症监护室 (ICU) 患者安全事件报告的48%,增强了学习文化和员工支持,而不损害整体安全文化.
科学领域:
- 改善医疗保健质量 改善医疗保健质量
- 患者安全 患者安全
- 密集护理医学 密集护理医学
背景情况:
- 在COVID-19大流行期间,在重症监护室 (ICU) 报告的患者安全事件明显低于国家基准.
- 报告不足的患者安全事件阻碍了风险意识和组织从近乎失误中学习.
- 报告的下降需要制定改善数据收集和安全文化的策略.
研究的目的:
- 将ICU患者安全事件报告数量增加30% (从27个报告增加到35个报告/1000个患者日).
- 实施多方面的质量改善干预措施,以加强报告.
- 确保干预措施不会对患者护理人员对安全感知的文化产生负面影响.
主要方法:
- 在9个ICU进行了前性干预研究.
- 多方面的干预包括建立患者安全同行领导角色,反过程,交互式数据仪表板和可访问的教育资源.
- 每1000个患者日的患者安全事件报告是主要结果;工作人员调查评估了安全文化.
主要成果:
- 患者安全事件报告在干预后增加了48% (40对27报告/1000个患者日),超过了目标.
- 员工对患者安全的总体评价保持稳定,但在学习文化和对参与事件的员工的支持方面取得了显著改善.
- 护士是主要的记者,提交超过80%的所有事件报告.
结论:
- 多方面的质量改善干预措施有效地提高了ICU患者安全事件报告率.
- 在学习文化和员工支持方面观察到的改进凸显了强大的报告系统的关键作用.
- 维持强大的安全机构文化得到了有效的患者安全事件报告机制的支持.
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