一个框架来分析医疗保健中的沟通错误
John A Bender1, Sreedevi Thiyagarajan, Wendy Morrish
1Department of Veterans Affairs, VHA National Center for Patient Safety, Ann Arbor, Michigan.
Journal of patient safety
|December 20, 2024
概括
这项研究开发了一种分类和框架工具,用于对患者安全事件中9种类型的沟通失败进行分类. 这些工具有助于识别和减轻来自错误的风险,例如程序不遵守和不良文档.
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
- 医疗信息学 医疗信息学
背景情况:
- 通信故障是患者安全事件的一个重要因素.
- 现有的分类通信错误的方法缺乏系统的方法.
- 需要一个标准化的分类学来有效地分析和解决这些失败.
研究的目的:
- 开发一种系统的方法来识别和分类通信故障.
- 为通信错误创建一个分类学代码表.
- 建立一个框架工具来分类通信错误类型.
主要方法:
- 使用德尔菲方法进行观测研究.
- 为通信错误开发一个分类学代码表.
- 应用自然语言处理 (NLP) 来创建框架工具.
- 退伍军人卫生管理局患者安全数据分析 (2018年4月 - 2021年3月).
主要成果:
- 确定了9种不同类型的影响患者安全的通信故障.
- 最常见的错误包括不遵守标准操作程序 (37.6%),书面错误 (22.3%) 和没有沟通 (13.2%).
- 开发了一个认知辅助器,以指导使用分类框架.
结论:
- 开发的框架工具和认知辅助提供了一种系统的方法来识别和分类通信失败.
- 这些工具可以在任何医疗环境中实施,以减轻与患者安全事件相关的风险.
- 标准化分类在有针对性的干预中有助于改善医疗保健沟通.
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