避免在骨科院内从不发生事件:质量改进项目
Bhaskar Amarnath Bhavanasi1, Shrikant Kulkarni2
1Trauma & Orthopaedics, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK bhaskar.bhavanasi@nhs.net.
BMJ open quality
|January 27, 2025
概括
非手术人员定期进行审计显著改善了对手术和成像暂停协议的遵守,减少了骨科院内从未发生的事件. 这提高了患者的安全和工作人员的信心.
科学领域:
- 外科手术的安全性
- 改善患者护理的改善
- 医疗保健审计 医疗保健审计
背景情况:
- 在54%的手术室病例中,从未发生过事件,即关键患者安全事件.
- 这些事件造成了严重的压力,并损害了创伤和骨科环境中的患者安全.
- 遵守手术暂停和成像暂停协议对于预防此类事件至关重要.
研究的目的:
- 为了减少创伤和骨科剧院的永远不会发生的事件.
- 确保剧院工作人员始终遵循手术暂停和成像暂停协议.
- 实施定期审计,以监测和改善协议的遵守.
主要方法:
- 在创伤和选择性骨科剧院进行前性研究.
- 非手术团队成员在随机日进行的审计.
- 观察遵守手术和成像暂停协议,包括患者验证和成像确认.
主要成果:
- 观察到遵守手术和成像暂停协议的实质性增加.
- 相应地减少了从未发生的事件的发生.
- 剧院工作人员报告说,他们对安全程序有了更好的理解和信心.
结论:
- 非手术人员定期进行的审计有效地提高了对安全协议的遵守.
- 这种系统的方法显著减少了骨科手术中从未发生的事件.
- 持续的监测和教育促进了手术实践中安全和精确的文化.
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