将"行动"放在RCA中:在不良事件发生后干预强度的分析
概括
医院经常在安全事件中使用多个纠正措施,但更强大的干预措施不太可能完成. 专注于完成高强度行动的障碍,可以提高患者的安全性和可靠性.
科学领域:
- 改善医疗保健质量 改善医疗保健质量
- 患者安全研究的研究.
- 医院管理部门 医院管理部门
背景情况:
- 美国医院已经建立了安全事件报告和审查的系统.
- 改善患者安全的实施系统较不发达.
研究的目的:
- 分析安全事件的促成因素和纠正措施.
- 评估纠正行动的强度和完成率.
- 确定实施有效的患者安全干预措施的障碍.
主要方法:
- 从2020-2021年开始对67个安全事件进行潜在的贡献因素和纠正行动的收集.
- 使用美国退伍军人事务部/医疗保健改进研究所行动等级工具,对纠正行动进行回顾性编码.
- 追踪到2023年的纠正行动完成情况.
主要成果:
- 确定了15个贡献因素主题和148个纠正措施.
- 85.1%的事件有多个纠正措施.
- 大多数纠正措施 (56.8%) 被评为弱,较强干预措施的完成率较低 (强干预措施为73.3%,弱干预措施为97.6%).
结论:
- 安全事件经常涉及多个纠正措施.
- 干预的强度与其完成率之间存在反向关系.
- 整合行动实力和完成状态可以帮助医疗保健组织解决实施高影响力患者安全策略的障碍.
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