在爱尔兰的长期护理设施中造成不良事件的因素,内容分析
Niall McGrane1, Paul Dunbar1, Laura M Keyes1
1Health Information and Quality Authority, Cork, Ireland.
Journal of the American Medical Directors Association
|December 23, 2023
概括
居民因素和不安全行为是导致长期护理机构不良事件的关键因素. 需要改进报告和系统设计,以提高居民安全并减少伤害.
科学领域:
- 医疗保健的质量和安全
- 老年学是一门学科.
- 关于残疾人的研究.
背景情况:
- 对不良事件 (AE) 的研究在急性护理方面广泛,但在长期护理设施 (LTCF) 方面有限.
- 了解LTCF中的AE贡献者对于改善老年人和残疾人的护理至关重要.
研究的目的:
- 确定导致长期护理机构不良事件的因素.
- 为LTCFs的弱势群体提供质量改善计划的信息.
主要方法:
- 来自爱尔兰LTCF的法定AE通知的内容分析 (2018-2019,n=156).
- 使用修改的人类因素分析和分类系统 (HFACS) 进行因素识别.
- 为了确保可靠性,两位研究人员进行了独立分析.
主要成果:
- 在所有HFACS级别中确定了促成因素.
- "居民因素" (43.6%的通知缺乏确定的因素) 和"不安全行为"是最常见的贡献因素.
- 严重的伤害占了最大的百分比 (27.4%).
结论:
- 临床医疗机构必须将"居民因素"纳入系统设计,风险管理和护理规划.
- 积极识别居民风险可以减轻高风险事件并提高安全性.
- 很大一部分通知缺乏确定的因素,表明需要改进LTCF报告和标准化通知表格.
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