从责备到学习:伦敦患者安全协议的演变
Francesco De Micco1,2, Gianmarco Di Palma1,2, Vittoradolfo Tambone1
1Research Unit of Bioethics and Humanities, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, 00128 Roma, Italy.
Healthcare (Basel, Switzerland)
|August 28, 2025
概括
2024年伦敦议定书通过从以事件为重点的审查转向系统分析,促进更深入的调查和利益相关方参与,以提高医疗保健系统的弹性.
科学领域:
- 医疗保健管理
- 患者安全科学
- 临床风险管理
背景情况:
- 患者安全和临床风险管理是全球医疗保健的优先事项.
- 伦敦议定书是调查不良事件的关键方法.
- 2004年的框架已经更新到2024年的版本.
研究的目的:
- 批判性地研究"2024年伦敦议定书"的结构,原则和创新.
- 突出它从以事件为中心的分析发展到对失败和成功的更广泛的理解.
- 讨论它作为医疗保健文化转型的催化剂的作用.
主要方法:
- 系统性,非惩罚性镜头用于不良事件调查.
- 整合安全科学,人为因素和数字健康的进步.
- 强调弹性,主动学习和利益相关者的参与.
主要成果:
- 转向更少的深入调查和可行的建议.
- 更多地关注患者和家属参与安全过程.
- 识别优势 (整体分析,协作) 和挑战 (复杂性,抗性).
结论:
- 伦敦2024年议定书促进了向更安全,更有弹性医疗保健的文化转型.
- 克服挑战需要领导力,员工参与和数字技术.
- 通过分析失败和成功,
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