扩大患者安全事件的定义:多中心学习健康系统协作系统的经验教训
Jeanne M Huddleston1,2, Daniel Whitford2, Alexandra K Yaszemski3
1Mayo Clinic, Red Wing, Minnesota, USA.
BMJ open quality
|February 19, 2025
概括
一种新的标准化方法来审查患者病例,确定了医疗保健的重大改进机会 (OFI). 大多数OFI源于护理方面的遗漏,突出了提高患者安全的关键领域.
科学领域:
- 医疗保健质量和安全研究
- 医疗信息学和数据分析
- 医疗服务研究 医疗服务研究
背景情况:
- 患者安全仍然是医疗保健中的持续挑战,尽管投入了大量资金,但仍有逐步改善.
- 识别安全事件受到方法不一致和缺乏标准化的阻碍.
- 这项研究解决了对评估患者安全和确定改进机会 (OFI) 的标准化方法的需求.
研究的目的:
- 评估标准化案例审查方法和安全事件分类学的可行性.
- 评估各种医院设置的改进机会 (OFI).
- 将标准化方法的发现与患者安全的传统定义进行比较.
主要方法:
- 一项多中心的回顾性队列研究,涉及美国和加拿大的103家医院 (2016-2023年).
- 使用标准化案例审查方法和安全事件分类学.
- 采用多变量物流回归分析OFI基于医院特征和患者人口统计数据.
主要成果:
- 审查了19,181个案件,其中66.3%的案件中至少发现了一个OFI.
- 医院的特点和患者因素 (年龄,停留时间,代码状态,出院处置) 与OFI有显著的关联.
- 大多数被确定的OFI (89%) 与疏忽关怀有关,特别是在生命终点,文档和治疗/护理类别.
结论:
- 一种标准化的案例审查方法有效地确定了许多改进机会 (OFI).
- 疏忽代表了与安全相关的OFI中最重要的类别.
- 调查结果表明,需要扩大患者安全的定义,以更全面地涵盖护理疏忽.
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