医院跌倒报告不足:韩国一项多站点研究
Insook Cho1,2, Joon-Myoung Kwon3, Whasuk Choe4
1School of Nursing, Inha University, Incheon, The Republic of Korea insook.cho@inha.ac.kr.
BMJ quality & safety
|March 26, 2025
概括
医院的防摔方案显示,在事件报告方面存在显著的实践差异和弱点. 改进的系统对于减少临床环境中患者跌倒和受伤至关重要.
科学领域:
- 改善医疗保健质量 改善医疗保健质量
- 患者安全研究的研究.
- 临床风险管理临床风险管理
背景情况:
- 住院患者跌倒是由于复杂的环境和患者风险相互作用而导致患者受伤的不良事件.
- 医院倒在临床环境中仍然是一个重大挑战,需要改进管理策略.
研究的目的:
- 识别医院病例管理协议中的变化和问题,从检测到干预.
- 探索潜在的方法,以应对住院患者跌倒预防方面的挑战.
主要方法:
- 追溯队列研究分析了来自韩国四家普通医院 (2015-2023) 的定性和定量数据.
- 利用多纳贝迪安的质量结果模型,包括协议的内容分析,图表审查和护理活动和干预措施的定量分析.
- 数据来源包括电子记录和事件自我报告.
主要成果:
- 在各医院的秋季定义,风险评估工具和协议标准中观察到显著的差异.
- 跌倒风险评估的启发式工具显示性能差到中等 (AUC 0.540.80).
- 预防性干预仅在有风险的患者中达到1.15%49.5%,系统下跌事件 (29.5%90.6%) 和护理笔记 (4.4%17.1%) 报告不足.
结论:
- 当地落协议设计和实施的缺陷,加上不良的事件报告系统,阻碍了有效的防.
- 系统和可持续的解决方案对于降低医院跌倒率和相关伤害至关重要.
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