在耳鼻喉科-头手术中发现系统间医疗错误
Ruby J Kazemi1,2, Alexis G Antunez3, Nicholas R Lenze4
1University of Michigan Medical School, Ann Arbor.
JAMA otolaryngology-- head & neck surgery
|May 8, 2025
概括
由于系统和个人障碍,耳鼻科医生对系统间医疗错误发现 (IMED) 的处理不佳. 需要标准化流程和培训,以改善这些关键患者安全事件的反和报告.
科学领域:
- 医学错误分析 医学错误分析
- 患者安全研究的研究.
- 耳鼻喉科的质量改善
背景情况:
- 系统间医疗错误发现 (IMED) 涉及识别发生在一个设施之外的错误.
- 尽管IMED对患者安全和护理质量产生影响,但IMED的明确指南有限.
- 由于复杂的条件和子专业化,IMED在耳鼻喉学中是一个重要的关注点.
研究的目的:
- 探索耳鼻喉科医生对IMED的反和报告的看法和做法.
- 确定预防或应对系统间医疗错误的策略.
主要方法:
- 使用半结构化的虚拟访谈进行定性研究.
- 采访了24名具有患者安全和质量改善专业知识的耳鼻喉科医生.
- 有目的的抽样确保了分专业,职业阶段,地理,实践背景和人口统计的多样性.
主要成果:
- 阻碍IMED反/报告的障碍包括后勤,心理社会和结构因素.
- 反/报告的促进者涉及严重,严重或重复的错误,以及现有关系.
- 大多数参与者认为IMED的解决方案不足,提出了反培训和标准化指南等解决方案.
结论:
- 缺乏标准化的流程和资源阻碍了有效的IMED响应.
- 有机会改善IMED的临床实践和卫生系统政策.
- 加强反和报告机制对于整个医疗保健系统的患者安全至关重要.
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