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加强烧伤重症监护室的责任转移:一个质量改善倡议
Gavin Shantz1, Anita Au1, Ashley Callahan1
1Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
概括
在烧伤重症监护室 (ICU) 实施标准化责任转移 (TOA) 工具显著减少了50%的患者安全事件,并提高了20%的安全文化. 这种共同设计的工具提高了护士的沟通和清晰度.
科学领域:
- 护理工作
- 患者安全
- 提高质量
背景情况:
- 在烧伤重症监护室 (ICU) 中,有效的护士交换对于患者的安全至关重要.
- 在责任转移 (TOA) 期间的沟通缺口导致可预防的安全事件.
研究的目的:
- 设计和实施标准化的,针对烧伤的TOA工具,以改善烧伤病房的患者安全和安全文化.
- 减少与交付相关的通信故障和相关的安全事件.
主要方法:
- 一个质量改善的倡议涉及与前线护士共同开发一个结构化的TOA工具.
- 该工具通过有针对性的教育和八个每周的计划-做-学习-行动 (PDSA) 周期实施.
- 测量结果包括事件率,安全文化得分和工具坚持.
主要成果:
- 安全事件减少了50% (从每月18起降至9起).
- 护士报告的安全文化得分提高了20%.
- 护士报告了提高清晰度和降低认知负载的情况.
结论:
- 一个共同设计的TOA工具,在教育和代改进的支持下,有效地提高了烧伤重症监护室的交付安全性.
- 这一举措为改善高风险临床环境中的沟通和安全文化提供了一个可扩展的模型.
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