确定四级护理医院事件报告的障碍
Anitha Loganathan1, Lallu Joseph2, Bheema Rao Rabindaranth2
1Quality Management Cell, Christian Medical College Vellore, Vellore, Tamil Nadu, India anithalog09@gmail.com.
BMJ open quality
|February 3, 2026
概括
担心惩罚和缺乏匿名性是南印度医疗保健专业人员报告事件的主要障碍. 改善报告需要一种非惩罚性的文化和增强的反机制.
科学领域:
- 改善医疗保健质量 改善医疗保健质量
- 患者安全研究的研究.
- 医学错误分析 医学错误分析
背景情况:
- 有效的事件报告系统对于提高患者安全和医疗保健质量至关重要.
- 报告障碍可能会阻碍医疗错误的识别和减轻.
- 了解这些障碍对于制定有针对性的干预措施至关重要.
研究的目的:
- 调查医疗保健专业人员在南印度四级护理医院内报告事件时遇到的障碍.
- 确定医生,护士和相关卫生专业人员在事件报告方面面临的具体挑战.
主要方法:
- 进行了一项横截面研究,涉及1784名医疗保健专业人员,使用系统的随机抽样.
- 从2023年5月到6月收集数据,并使用描述性统计和推断测试 (χ2,ANOVA) 进行分析.
- 响应率为35% (629名参与者),包括医生,护士和相关卫生专业人员.
主要成果:
- 事件报告因职业而异:相关卫生专业人员 (65%),护士 (39%) 和医生 (27%).
- 护士报告的事件数量最多 (n=170),主要与药物相关 (n=92) 和患者安全问题 (n=69).
- 关键障碍包括对惩罚性行动的恐惧 (在相关卫生专业人员中最高),身份追踪问题以及缺乏匿名感,具有显著的群体间差异 (p<0.05).
结论:
- 个人层面的障碍,特别是对报复的恐惧和不充分的匿名性,大大阻碍了事件报告.
- 医疗保健领导层必须培养一种非惩罚性的,保密的报告文化,并改进反循环.
- 未来的质量改进工作应该考虑简化流程和扩大培训,尽管它们的有效性需要进一步测试.
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