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将高可靠性原则应用于输液安全性:多站点卫生系统的案例研究
Ann M West1, Nicole L Schueler2, Rachel A Moody3
1Quality, Mayo Clinic Health System, Mankato.
Journal of patient safety
|September 8, 2025
概括
一个高可靠性的框架解决了输液故障,防止了严重的患者伤害. 持续的警和跨学科的合作是改善医疗保健安全和质量结果的关键.
科学领域:
- 医疗保健安全工程 医疗保健安全工程
- 医疗器械风险管理 医疗器械风险管理
- 患者安全系统 患者安全系统
背景情况:
- 输液是关键的医疗设备,存在潜在的安全问题,如过量/不足输液和闭塞报警.
- 一个大型的多站点医疗保健系统面临着输液故障的重大挑战,包括上游阻塞报警的29%故障率.
研究的目的:
- 通过使用高可靠性原则框架,识别,调查和减轻输注安全问题.
- 开发一种系统的方法来应对输液的挑战,并提高患者的安全.
主要方法:
- 应用了五个高可靠性原则:关注失败,尊重专业知识,对操作敏感,不愿简化,以及弹性实践.
- 建立了一个多学科的团队,进行了人为因素评估,分析了药物特定因素,并评估了管道特性.
主要成果:
- 启动了全国性召回故障,并制定了全系统的培训和缓解协议.
- 优化了内部患者安全系统和流程,成功地防止了严重的患者伤害,尽管持续存在的挑战.
结论:
- 持续的警,跨学科的合作,并拥抱复杂性是提高大型医疗机构的患者安全至关重要的.
- 将高可靠性原则整合到整个医疗保健服务中,对于持续改善安全和质量结果至关重要.
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