Collaborative Case Review: A Systems-Based Approach to Patient Safety Event Investigation and Analysis.
Collaborative Case Review: A Systems-Based Approach to Patient Safety Event Investigation and Analysis.
复制标题
DOI：
10.1097/pts.0000000000000857
复制
发表时间：
2022-03-01
影响因子：
2.2
通讯作者：
Eappen S
中科院分区：
文献类型：
--
作者：
Lacson R;Khorasani R;Fiumara K;Kapoor N;Curley P;Boland GW;Eappen S
本研究的目的是评估一种基于系统的事件调查和分析方法-合作病例回顾(CCRs) -并测量临床专业对规定的行动项目强度的影响。由放射科和机构患者安全计划共同领导的完全集成的CCR流程于2017年11月1日在我们的大型学术医疗中心实施，用于评估涉及放射学的不良事件。质量和安全团队与维护现有流程的其他部门一起对事件进行审查。这份机构审查委员会批准的研究报告描述了该计划，包括机构电子安全报告系统的CCR百分比，每个专业的CCR百分比，以及基于退伍军人管理局设计的等级制度的行动项目完成率和强度（例如，更强）。χ2分析评估临床专科对处方药物强度的影响。2018年的73项CCR产生了10个专业的260个行动项目。70%（51/73）是通过电子安全报告系统确定的不良事件。最常与CCR相关的专业是放射学（16/ 73,22%）。大部分行动项目（204/260,78%）在1年内完成；260个项目中有71个（27%）完成了较强的行动项目。放射学负责61项行动项目；61个专业中有25个（41%）是强的，而199个专业中有46个（23%）是强的（P < 0.01）。与其他医院部门相比，由放射科和机构患者安全计划共同领导的综合多专业CCR与更高比例的CCR、更强的行动项目和更高的行动项目完成率相关。积极参与CCR可以提供解决不良事件和促进患者安全的见解。
The aims of the study were to assess a system-based approach to event investigation and analysis—collaborative case reviews (CCRs)—and to measure impact of clinical specialty on strength of action items prescribed. A fully integrated CCR process, co-led by radiology and an institutional patient safety program, was implemented on November 1, 2017, at our large academic medical center for evaluating adverse events involving radiology. Quality and safety teams performed reviews for events identified with other departments who maintained their existing processes. This institutional review board–approved study describes the program, including percentage of CCR from an institutional Electronic Safety Reporting System, percentage of CCR per specialty, and action item completion rates and strength (e.g., stronger) based on a Veterans Administration–designed hierarchy. χ2 analysis assessed impact of clinical specialty on strength of action prescribed. Seventy-three CCR in 2018 generated 260 action items from 10 specialties. Seventy percent (51/73) were adverse events identified through Electronic Safety Reporting System. The specialty most frequently associated with CCR was radiology (16/73, 22%). Most action items (204/260, 78%) were completed in 1 year; stronger action items were completed in 71 (27%) of 260. Radiology was responsible for 61 action items; 25 (41%) of 61 were strong versus all other specialties with strong action items in 46 (23%) of 199 (P < 0.01). An integrated multispecialty CCR co-led by the radiology department and an institutional patient safety program was associated with a higher proportion of CCR, stronger action items, and higher action item completion rate versus other hospital departments. Active engagement in CCR can provide insights into addressing adverse events and promote patient safety.