使用行为改变轮检查患者安全事件:一个横截面分析
Joint Commission journal on quality and patient safety
|December 17, 2024
概括
前体级安全事件 (PSE) 显示干预措施与其根本原因之间的调整不佳. 许多干预措施,如教育,对于已识别的行为是无效的,需要改进,行为知情报告和干预策略.
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 患者安全研究
- 医学中的行为科学.
背景情况:
- 前体级安全事件 (PSEs) 代表了患者的重大风险,但其潜在原因仍然不太清楚.
- 确定PSE的决定因素对于开发有效的患者安全干预措施至关重要.
- 现有的研究缺乏对推动公共服务企业的因素的全面了解.
研究的目的:
- 应用行为变化轮 (BCW) 框架来理解PSE的决定因素.
- 评估已识别的PSE决定因素与拟议的干预行动项目之间的一致性.
- 评估目前针对公共事业企业的干预策略的有效性.
主要方法:
- 一项横截面研究分析了58个在母婴医院预先记录的PSE.
- 行为变化轮 (BCW) 用于独立编码每个PSE的决定因素和行动项目.
- 一个矩阵分析了行为决定因素和干预类型之间的对齐.
主要成果:
- 在58个PSE中确定了6个行为决定因素和7种干预类型.
- 环境背景/资源 (25.4%) 是最常见的决定因素;教育 (45.8%) 是最常见的干预措施.
- 只有34.2%的决定因素与干预措施保持一致,而37.8%没有,而28.1%缺乏足够的编码信息.
结论:
- 公共服务企业的决定因素与实施的干预措施之间存在显著的脱节,超过三分之一的干预措施表现出不良协调.
- 教育干预措施,通常对确定的行为无效,被不成比例地使用.
- PSE报告中的有限信息阻碍了准确的评估,突出了对患者安全有系统,行为知情的方法的需要.
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