用于自愿不良事件报告的麻醉专用软件模块。

IF 1.7 3区 医学 Q3 HEALTH CARE SCIENCES & SERVICES Journal of Patient Safety Pub Date : 2025-01-01 DOI:10.1097/PTS.0000000000001290
Karolina Brook, Su Yeon Song, Julianna Richards, Laura Harrington, Nana Kwame Okyere-Tawiah, R Mauricio Gonzalez
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引用次数: 0

摘要

目的:医院工作人员应向安全领导和风险管理人员报告不良事件。在我们的机构,员工通过事件报告软件系统报告不良事件,称为“RL”。这些“RL报告”与病人的医疗记录分开保存。在麻醉科,我们注意到相对于已知的不良事件,RL报告的数量较少。与麻醉相关的事件分散在RL软件中,因此很难发现。我们假设将这些事件汇编在一个地点将增加报告率,并允许更深入地分析已归档的不良事件。方法:我们创建了一个麻醉特异性RL软件模块,该模块将所有与麻醉相关的不良事件集中在一个位置。此外,我们亦追踪研究期间推行的另外两项质素改善措施,包括一项部门内部质素保证表格,对研究报告的影响。结果:麻醉RL软件模块使RL月平均报告数增加3.2倍(P < 0.001)。当排除最普遍的RL报告类别(受控物质差异)时,增幅甚至更大(11.1倍,P < 0.001)。部门内部质量保证表对提交的RL报告影响最小。“受控物质差异”、“其他”和“设备问题”是最常见的事件类型。大多数事件被归类为对病人没有伤害。结论:创建一个专门的RL软件模块可以增加RL报告,即使考虑到其他实施的质量改进计划,并允许对归档报告进行更深入的分析。我们的发现可能在其他专业中得到复制。
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Anesthesia-Specific Software Module for Voluntary Adverse Event Reporting.

Objectives: Hospital staff are expected to report adverse events to safety leaders and risk managers. At our institution, staff report adverse events via an incident reporting software system, known as "RL." These "RL reports" are kept separate from patient medical records. Within the Anesthesiology Department, we noted low numbers of RL reports relative to known adverse events. Anesthesiology-related events were scattered within the RL software and therefore difficult to find. We hypothesized that compiling these events in one location would increase reporting rates and allow for deeper analysis of filed adverse events.

Methods: We created an Anesthesia-specific RL software module, which included all anesthesia-related adverse events in one location. Additionally, we tracked the impact on RL reporting of two other quality improvement initiatives, including an intradepartmental quality assurance form, implemented during the study period.

Results: The Anesthesia RL software module led to a 3.2-fold increase (P < 0.001) in the monthly average of filed RL reports. The increase was even greater (11.1-fold, P < 0.001) when excluding the most prevalent category of RL reports (Controlled Substance Discrepancies). The intradepartmental quality assurance form had minimal impact on filed RL reports. "Controlled Substance Discrepancies," "Other," and "Equipment issue" were the most common event types. Most events were classified as constituting no harm to the patient.

Conclusions: Creating a specialty-specific RL software module led to increased RL reports, even when accounting for other implemented quality improvement initiatives, and allowed for deeper analysis of the filed reports. Our findings may be replicated for other specialties.

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来源期刊
Journal of Patient Safety
Journal of Patient Safety HEALTH CARE SCIENCES & SERVICES-
CiteScore
4.60
自引率
13.60%
发文量
302
期刊介绍: Journal of Patient Safety (ISSN 1549-8417; online ISSN 1549-8425) is dedicated to presenting research advances and field applications in every area of patient safety. While Journal of Patient Safety has a research emphasis, it also publishes articles describing near-miss opportunities, system modifications that are barriers to error, and the impact of regulatory changes on healthcare delivery. This mix of research and real-world findings makes Journal of Patient Safety a valuable resource across the breadth of health professions and from bench to bedside.
期刊最新文献
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