在哨戒事件分析中对提高患者安全性的评级建议:推改进矩阵
Kelly Bos1, Maarten J van der Laan1, Jop Groeneweg2,3
1Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands.
BMJ open quality
|April 16, 2024
概括
一个新的分级系统,推改进矩阵 (RIM),被开发来评估患者安全建议. 该工具有助于提高干预措施的质量和选择,以防止哨兵事件 (SE).
科学领域:
- 患者安全 患者安全
- 改善医疗保健质量 改善医疗保健质量
- 风险管理 风险管理
背景情况:
- 哨兵事件 (SE) 经常发生,由于次于最佳的建议,其发生率保持不变.
- 缺乏标准化的方法来选择或设计有效的建议,阻碍了患者安全的改善.
- 制定分级系统对于识别具有防止SE复发潜力最高的干预措施至关重要.
研究的目的:
- 开发一种易于使用的方法来对来自哨兵事件分析的建议进行分级.
- 通过荷兰的SE报告来评估这种分级方法的适用性.
- 评估SE分析中建议的质量和分布.
主要方法:
- 推改进矩阵 (RIM) 是基于两个现有的分级方法开发的.
- 在12个月内,RIM应用于来自115个荷兰SE报告中的161个建议.
- 观察者间协议被评估以确定RIM的可靠性.
主要成果:
- 该RIM根据干预时间 (SE前或后) 和危险控制 (消除或控制) 分类建议.
- 建议的质量差异很大,A类 (44%) 和B类 (35%) 是最有效的,而C类 (2%) 和D类 (19%) 的影响较小.
- 达成了公平的观察者间协议,表明了RIM的可靠性.
结论:
- 推改进矩阵 (RIM) 提供了一个用于对SE推进行分级的实用工具.
- RIM可以帮助设计和选择更有效的干预措施,从而提高患者的安全性.
- 该系统旨在促进对话,并促进创建可持续,有影响力的患者安全建议.
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