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医院管理人员进行根本原因分析的经验:在哨兵事件发生后的案例研究
Silje Liepelt1, Ralf Kirchhoff1
1Department of Health Sciences, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Ålesund, Norway.
医院管理人员在哨兵事件后进行根源原因分析 (RCA) 时面临挑战和情绪紧张. 为了有效的患者安全调查,需要加强支持和明确的角色.
科学领域:
- 医疗保健管理的管理
- 患者安全 患者安全
- 定性研究是指质量研究.
背景情况:
- 根源原因分析 (RCA) 是医疗保健中的关键患者安全工具.
- 这项研究检查了医院管理人员在警卫事件发生后对RCA的经验:婴儿在分娩期间死亡.
- 该事件发生在2021年挪威一家医院.
研究的目的:
- 探索医院管理人员进行根本原因分析的经验.
- 在RCA过程中识别挑战和支持需求.
主要方法:
- 定性,探索性的单个案例设计.
- 与医院管理人员进行了9次半结构面试.
- 分析RCA指南,报告和内部程序.
主要成果:
- 管理人员在遵守挪威RCA方法时遇到了挑战,包括实际应用和沟通问题.
- 管理人员经历了相当大的情绪负担,管理员工的悲伤和家庭沟通.
- 角色的模糊性和监管合规性是关键的困难.
结论:
- 有效的RCA需要更清晰的角色定义,更好的资源和强大的情感支持系统.
- 将国家指导方针适应现实世界的约束对于成功的RCA至关重要.
- 管理人员在弥合监管期望和组织现实方面发挥着至关重要的作用.
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