在中等保健中严重事件调查后的行动计划中确定了风险控制:质量研究
Mohammad Farhad Peerally, Susan Carr, Justin Waring1
1Health Services Management Centre, University of Birmingham.
Journal of patient safety
|June 25, 2024
概括
严重事件调查往往未能解决所有促成因素,大多数推的风险控制是弱的和个性化的. 这限制了研究的转化为有效的系统性患者安全改进.
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:
- 有效的事件调查对于提高患者安全至关重要.
- 在调查报告中推的风险控制的质量会对其有效性产生重大影响.
- 之前的研究强调,需要改进将事故发现转化为可行的安全措施.
研究的目的:
- 从严重事件调查中确定风险控制的范围和强度.
- 将这些控制与已识别的促成因素进行映射.
- 描述拟议的风险控制的性质,以了解其有效性.
主要方法:
- 来自严重事件调查报告的126个行动计划的内容分析.
- 编码风险控制与有助于因素对抗.
- 评估风险控制强度,使用控制层次模型.
- 对拟议的风险控制特征进行主题分析.
主要成果:
- 15%的促成因素没有通过任何风险控制来解决.
- 在822项拟议的风险控制措施中,有74%被评为较弱,往往侧重于个体问题而不是系统问题.
- 确定的方法包括提高绩效,规范实践,改善环境,沟通,流程改进和纪律处分.
结论:
- 在将严重事件调查转化为系统性患者安全改进方面存在重大差距.
- 缺陷包括未解决的因素和弱小,个性化的风险控制的普遍性.
- 提高风险控制质量需要人为因素专业知识,改变理论方法,评估和共享学习.
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