公共医院中哨兵事件的根本原因分析:关于报道文化和贡献因素的混合方法研究
Hatice Esen Koç1, Nazife Ozturk1
1Research and Devalopment Department, Antalya Training and Research Hospital, Antalya, Turkey.
概括
通过使用数字和医疗保健工作者经验分析不良事件,提高医院患者和工作人员的安全性. 解决系统性问题和培养积极的报告文化是防止未来伤害的关键.
科学领域:
- 医疗保健管理的管理
- 患者安全研究 患者安全研究
- 职业健康 职业健康 职业健康
背景情况:
- 不良事件严重威胁医疗保健安全,需要有效报告和根本原因分析来学习医疗保健系统.
- 在土耳其,有限的研究从患者和工作人员的安全角度分析不良事件,缺乏综合的混合方法研究,整合定量和定性数据.
研究的目的:
- 在第三级公共医院系统评估患者和工作人员的安全.
- 分析不良事件报告,使用从医疗保健工作者经验中获得的定量数据和定性见解.
主要方法:
- 采用了并行的混合方法设计.
- 来自321份不良事件报告 (2023年1月至12月) 的定量数据使用描述性统计数据进行了分析.
- 通过使用主题和内容分析,分析了与10名医疗保健工作者进行半结构面试的定性数据.
主要成果:
- 报告了321起不良事件,35.5%与患者安全有关,64.5%与工作人员安全有关.
- 常见的员工安全事件包括利的仪器伤害;与护理过程相关的患者安全事件.
- 定性主题揭示了系统性缺陷,由于惩罚性认知而无效的报告,以及对专业人士的重大情感影响.
结论:
- 评估不良事件需要将数值数据与医疗保健工作者的感知和经验相结合.
- 优先战略包括加强报告文化,促进根本原因分析,确保心理安全,减少系统性风险,以提高患者和工人的安全.
相关概念视频
00:59Hospitals-II
1.2K
Hospitals provide inpatient and outpatient services. Inpatient services provide care to patients that stay in the hospital for an extended period, ranging from days to months. Examples of inpatient services include intensive care units, hospital wards, or surgeries. Outpatient services provide care to patients who come to a hospital for a diagnostic or treatment but do not stay overnight —for example, diagnostic tests, surgical procedures, or health education.
Nurses that work in...
Nurses that work in...
1.2K
01:28Hospitals-I
1.7K
Hospitals offer medical and surgical care to the sick and injured, along with accommodation while they recover. At the same time, they also provide outpatient, emergency, psychiatric, and rehabilitation services to meet various community needs. In addition to providing medical care, hospitals also act as hubs for medical research and training. Hospitals use clinical procedures and evidence-based practice standards to deliver patient care. To deliver safe and efficient care, a nurse must stay up...
1.7K
01:19Root-Locus Method
520
A cruise control system in a car is designed to maintain a specified speed automatically by adjusting the gas pedal. The system continuously measures the vehicle's speed and makes fine adjustments to the pedal to achieve this goal. The root locus method is particularly useful for understanding how the cruise control system's behavior changes under varying conditions, such as when the car goes uphill, downhill, or faces strong wind resistance.
This system can be represented by a block...
This system can be represented by a block...
520
03:02Primary and Secondary Growth in Roots and Shoots
60.7K
Vascular plants, which account for over 90% of the Earth’s vegetation, all undergo primary growth—which lengthens roots and shoots. Many land plants, notably woody plants, also undergo secondary growth—which thickens roots and shoots.
60.7K
01:23Binet's Contribution to Measures of Intelligence
1.8K
Alfred Binet, along with his student Théophile Simon, was tasked by the French Ministry of Education in 1904 to create a method for identifying students who struggled to learn through conventional classroom instruction. This initiative aimed to address overcrowding by placing such students in specialized schools. Binet and Simon developed an intelligence test comprising 30 tasks, ranging from simple commands, like touching one's nose or ear, to more complex tasks, such as drawing...
1.8K
01:23Wechsler's Contribution to Measures of Intelligence
2.1K
David Wechsler, a psychologist who worked with World War I veterans, developed a significant IQ test in 1939 called the Wechsler-Bellevue Intelligence Scale. This test was innovative because it combined several subtests that measured both verbal and nonverbal skills, reflecting Wechsler's belief that intelligence is a global capacity involving purposeful action, rational thinking, and effective interaction with the environment. This test later evolved into the Wechsler Adult Intelligence...
2.1K