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输液编程的独立双重检查:一种麻醉改善的努力,以减少伤害
Kavitha C Raghavan1, Jonathan D Burlison2, Edward M Sanders Ii1
1From the Division of Anesthesiology, St Jude Children's Research Hospital, Memphis, Tenn.
Pediatric quality & safety
|April 8, 2024
概括
实施麻醉输液的双供应商验证流程显著减少了不良药物事件 (ADEs),并防止了近乎失误. 这项质量改进倡议在不推迟案件启动的情况下获得了很高的坚持.
科学领域:
- 麻醉学 麻醉学
- 患者安全 患者安全
- 提高质量 提高质量
背景情况:
- 麻醉输液编程错误可能导致显著的药物不良事件 (ADEs).
- 需要在大量麻醉环境中减少这些错误.
研究的目的:
- 实施和评估一个独立的两家供应商输液编程验证流程.
- 在两年内将麻醉相关的ADEs降低到零.
主要方法:
- 使用改善模型框架与计划-做-研究-行动 (PDSA) 周期.
- 关键的驱动因素包括教育,培训,验证,视觉辅助工具,IT和安全文化.
- 实施了智能编程的独立双供应商验证,包括跟踪和文档.
主要成果:
- 发生了一次E级ADE,归因于验证失败.
- 通过验证过程,预防了13起B级近距离事故.
- 第二次验证的遵守率达到85%,并且持续,没有延迟的案件开始.
结论:
- 结构化的质量改进方法使得成功实施了麻醉输液的双供应商验证.
- 这一过程有效地减少了大量设置中的错误,而不会影响案例启动时间.
- 报告的文化和组织因素可以帮助其他机构在项目采用和可持续性方面.
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