出院对初级保健的危害:事故报告的混合方法分析

H. Williams, A. Edwards, P. Hibbert, P. Rees, Huw Prosser Evans, S. Panesar, B. Carter, G. Parry, M. Makeham, Aled Jones, A. Avery, A. Sheikh, L. Donaldson, A. Carson-Stevens
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引用次数: 68

摘要

出院对患者安全构成重大风险,多达五分之一的患者在出院后三周内出现不良事件。目的描述与从二级到初级保健出院相关的患者安全事件的频率和类型,以及通常描述的促成因素,以确定实践建议。采用混合方法分析了英格兰和威尔士598份来自国家报告和学习系统的与“出院”相关的患者安全事件报告。方法对数据进行详细编码(20%为双编码),采用描述性统计分析生成数据摘要,对报告的特殊案例样本进行专题分析。描述了事件类型、促成因素、类型和危害程度,为今后的实践提供了建议。结果共分析合格报告598份。四个主要主题是:出院沟通错误(n = 151;54%造成伤害);转介到社区护理的错误(n = 136;73%造成伤害);用药错误(n = 97;87%造成伤害);缺乏护理辅助用品,如敷料(n = 62;94%造成伤害)。常见的促成因素是工作人员因素(未遵循转诊协议);以及组织因素(缺乏明确的指导方针或低效的流程)。改进机会包括开发和测试符合商定最低信息要求的电子出院方法,以及向社区护理提供者提供统一的转诊系统;通过“安全出院”清单、出院协调员和家庭参与,促进安全文化。结论由于排放过程中的缺陷,造成了明显的危害。需要对这一领域的干预措施进行评估,并广泛分享经验。
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Harms from discharge to primary care: mixed methods analysis of incident reports
Background Discharge from hospital presents significant risks to patient safety, with up to one in five patients experiencing adverse events within 3 weeks of leaving hospital. Aim To describe the frequency and types of patient safety incidents associated with discharge from secondary to primary care, and commonly described contributory factors to identify recommendations for practice. Design and setting A mixed methods analysis of 598 patient safety incident reports in England and Wales related to ‘Discharge’ from the National Reporting and Learning System. Method Detailed data coding (with 20% double-coding), data summaries generated using descriptive statistical analysis, and thematic analysis of special-case sample of reports. Incident type, contributory factors, type, and level of harm were described, informing recommendations for future practice. Results A total of 598 eligible reports were analysed. The four main themes were: errors in discharge communication (n = 151; 54% causing harm); errors in referrals to community care (n = 136; 73% causing harm); errors in medication (n = 97; 87% causing harm); and lack of provision of care adjuncts such as dressings (n = 62; 94% causing harm). Common contributory factors were staff factors (not following referral protocols); and organisational factors (lack of clear guidelines or inefficient processes). Improvement opportunities include developing and testing electronic discharge methods with agreed minimum information requirements and unified referrals systems to community care providers; and promoting a safety culture with ‘safe discharge’ checklists, discharge coordinators, and family involvement. Conclusion Significant harm was evident due to deficits in the discharge process. Interventions in this area need to be evaluated and learning shared widely.
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