除了麻醉学中的不良事件之外:"意想不到的事件"和改善报告策略
Karolina Brook1,2, Molly Wilde3, Andrea Vannucci4
1Department of Anesthesiology, Boston Medical Center.
Current opinion in anaesthesiology
|September 9, 2024
概括
在麻醉学中,超出不良事件 (AE) 的意外事件 (UE) 的跟踪,为提高患者安全提供了新的机会. 持续监测UE可以帮助识别风险,并在发生危害之前预防危害.
科学领域:
- 麻醉学 麻醉学
- 患者安全 患者安全
- 改善医疗保健质量 改善医疗保健质量
背景情况:
- 麻醉学中的患者安全已经取得了进展,但当前的改善策略集中在不良事件 (AE) 和近乎失误.
- 这种狭的重点忽视了有价值的数据,可能会阻碍进一步改善护理.
研究的目的:
- 将意外事件 (UE) 引入并定义为偏离预期护理的事件的更广泛类别.
- 突出当前数据收集方法的局限性,并提出扩展方法,以提高麻醉学的质量.
主要方法:
- 审查现有术语,包括AEs和非例行事件 (NREs).
- 介绍和定义意外事件 (UE).
- 讨论数据采集的自动化和自我报告工具以及质量/安全领导者在数据监控中的作用.
主要成果:
- 意想不到的事件 (UE) 包括AE和其他例行不追踪的麻醉事件.
- 用户体验允许进行趋势分析,识别额外的质量改进机会.
- 审查了现有的数据采集和监控工具.
结论:
- 一贯报告和监测UE可以使积极的风险识别和减轻危害.
- 建议在麻醉实践中扩大数据收集以包括UEE.
- 为有效的UE跟踪,建议设置部门特定的报告接口.
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