综合作为一个框架,使复杂的医疗保健环境中的安全干预成为可能
Aarti Bavare1, Tiffany Wrenn2, Anne Lam3
1Critical Care Medicine, Baylor College of Medicine, Houston, Texas, USA acbavare@texaschildrens.org.
BMJ open quality
|January 17, 2025
概括
实施综合框架改善了安全事件报告 (SER) 分析和医疗保健中的行动. 这加强了审查流程,减少了开放的报告,并促进了针对性的安全干预.
科学领域:
- 改善医疗保健质量 改善医疗保健质量
- 患者安全 患者安全
- 卫生系统管理管理卫生系统管理
背景情况:
- 现有的安全事件报告 (SER) 系统缺乏统一的结构,以便快速分析和采取行动.
- 孤立的审查阻碍了对质量,安全,生产力和可靠性的全面评估.
研究的目的:
- 实施一个综合框架,用于全面的SER评估和干预.
- 改进分析和对安全事件报告采取行动的过程.
主要方法:
- 利用计划-做-学习-行动循环和一个团队的团队模型.
- 加强了SER访问,促进了多学科审查,使用故障模式和影响分析优先考虑行动,并启动了干预措施.
- 衡量过程完成,团队参与,开放报告的比例,启动/完成的行动,以及领导者的看法.
主要成果:
- 在18个月内,审查的SER比例从75%增加到99%.
- 从43%降低到5.3%的"开放" (无地址) SERs的比例.
- 成功推出和传播了许多本地和组织安全行动,改善了领导者的认知.
结论:
- 成功实施了可持续的,全面的 SER 审查,优先级和行动流程.
- 通过在一个大型医疗机构的综合框架,促进了安全干预.
- 在管理安全事件报告方面表现出更高的效率和有效性.
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