Enhancing patient safety: detection of in-hospital hazards and effect of training on detection (by training in a low-fidelity simulation Room of Improvement based on hospital-specific CIRS cases).

IF 1.3 Q4 HEALTH CARE SCIENCES & SERVICES BMJ Open Quality Pub Date : 2024-05-29 DOI:10.1136/bmjoq-2023-002608
Carina Graf, Christoph Alexander Rüst, Joachim Koppenberg, Miodrag Filipovic, Wolf Hautz, Juliane Kaemmer, Urs Pietsch
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Abstract

Importance: Adequate situational awareness in patient care increases patient safety and quality of care. To improve situational awareness, an innovative, low-fidelity simulation method referred to as Room of Improvement, has proven effective in various clinical settings.

Objective: To investigate the impact after 3 months of Room of Improvement training on the ability to detect patient safety hazards during an intensive care unit shift handover, based on critical incident reporting system (CIRS) cases reported in the same hospital.

Methods: In this educational intervention, 130 healthcare professionals observed safety hazards in a Room of Improvement in a 2 (time 1 vs time 2)×2 (alone vs in a team) factorial design. The hazards were divided into immediately critical and non-critical.

Results: The results of 130 participants were included in the analysis. At time 1, no statistically significant differences were found between individuals and teams, either overall or for non-critical errors. At time 2, there was an increase in the detection rate of all implemented errors for teams compared with time 1, but not for individuals. The detection rate for critical errors was higher than for non-critical errors at both time points, with individual and group results at time 2 not significantly different from those at time 1. An increase in the perception of safety culture was found in the pre-post test for the questions whether the handling of errors is open and professional and whether errors are discussed in the team.

Discussion: Our results indicate a sustained learning effect after 12 weeks, with collaboration in teams leading to a significantly better outcome. The training improved the actual error detection rates, and participants reported improved handling and discussion of errors in their daily work. This indicates a subjectively improved safety culture among healthcare workers as a result of the situational awareness training in the Room of Improvement. As this method promotes a culture of safety, it is a promising tool for a well-functioning CIRS that closes the loop.

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加强患者安全:院内危险的检测和培训对检测的影响(根据医院特定的 CIRS 案例,在低保真模拟改进室中进行培训)。
重要性:在患者护理过程中,充分的情景意识可提高患者安全和护理质量。为了提高情景意识,一种创新的低保真模拟方法被称为 "改善室",已在各种临床环境中被证明是有效的:根据同一家医院危急事件报告系统(CIRS)报告的案例,调查 "改善室 "培训 3 个月后对重症监护病房交接班期间发现患者安全隐患能力的影响:在这项教育干预活动中,130 名医护人员以 2(时间 1 vs 时间 2)×2(单独 vs 团队)的因子设计观察了改善室中的安全隐患。危害被分为紧急危害和非紧急危害:130 名参与者的结果纳入了分析。在第一时间,无论是整体还是非关键错误,个人和团队之间都没有发现明显的统计学差异。在第 2 个时间段,与第 1 个时间段相比,团队的所有已执行错误的检出率都有所提高,但个人的检出率则没有提高。在两个时间点,关键错误的发现率均高于非关键错误的发现率,个人和团队在第 2 个时间点的结果与第 1 个时间点的结果没有显著差异。在对错误的处理是否公开和专业以及是否在团队中讨论错误等问题的前后测试中,发现对安全文化的感知有所提高:讨论:我们的结果表明,12 周后学习效果持续,团队合作的结果明显更好。培训提高了实际的错误发现率,学员们表示在日常工作中对错误的处理和讨论有所改善。这表明,通过在 "改善室 "进行情景认知培训,医护人员的安全文化得到了主观改善。由于这种方法能促进安全文化,因此是一种很有前途的工具,能使 CIRS 闭环良好运作。
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来源期刊
BMJ Open Quality
BMJ Open Quality Nursing-Leadership and Management
CiteScore
2.20
自引率
0.00%
发文量
226
审稿时长
20 weeks
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