Risk assessment of the acute stroke diagnostic process using failure modes, effects, and criticality analysis.
Risk assessment of the acute stroke diagnostic process using failure modes, effects, and criticality analysis.
复制标题
使用故障模式、影响和关键性分析对急性中风诊断过程进行风险评估。
DOI：
10.1111/acem.14648
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发表时间：
2023
期刊：
影响因子：
--
通讯作者：
Prabhakaran,Shyam
中科院分区：
文献类型：
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作者：
Liberman,AvaL;Holl,JaneL;Romo,Elida;Maas,Matthew;Song,Sarah;Prabhakaran,Shyam
迄今为止，许多基于急诊科 (ED) 的针对急性中风患者的质量改进研究和干预措施都侧重于加快时间敏感的治疗，特别是减少就诊时间。然而，在治疗之前，必须做出中风的诊断。尽管基于 ED 的中风诊断过程对于确保高质量和安全的护理很重要，但它的研究尚未充分。方法我们利用学习协作对伊利诺伊州芝加哥的三个卫生系统的急性中风诊断过程进行了故障模式、影响和严重性分析 (FMECA)。我们的 FMECA 旨在前瞻性地识别、描述和排序护理系统和流程中的故障，从而提供重新设计的机会，以提高中风诊断的准确性。五个不同地点参与中风护理的多学科团队参加了主持会议，以创建急性中风诊断流程图，并确定失败和现有的保障措施。对于每次故障，都会计算风险优先级编号和关键性分数。然后对失败进行排名，最高分代表需要重新设计的最关键失败。结果在急性中风诊断过程中总共确定了 28 个步骤。该过程中的迭代步骤包括信息收集、临床检查、诊断测试结果的解释和重新评估。我们发现，在急诊科早期未能使用现有筛查量表来识别大血管闭塞患者的排名最高。未能获得指标事件的准确病史、未能在分诊中怀疑急性中风以及未能在急诊室到达时使用现有的中风筛查工具来识别潜在的中风患者也排名靠前。结论我们的研究结果强调了急性中风诊断过程中上游步骤的至关重要性，特别是使用现有工具来识别可能有资格接受时间敏感治疗的中风患者。
IntroductionTo date, many emergency department (ED)‐based quality improvement studies and interventions for acute stroke patients have focused on expediting time‐sensitive treatments, particularly reducing door‐to‐needle time. However, prior to treatment, a diagnosis of stroke must be reached. The ED‐based stroke diagnostic process has been understudied despite its importance in assuring high‐quality and safe care.MethodsWe used a learning collaborative to conduct a failure modes, effects, and criticality analysis (FMECA) of the acute stroke diagnostic process at three health systems in Chicago, IL. Our FMECA was designed to prospectively identify, characterize, and rank order failures in the systems and processes of care that offer opportunities for redesign to improve stroke diagnostic accuracy. Multidisciplinary teams involved in stroke care at five different sites participated in moderated sessions to create an acute stroke diagnostic process map as well as identify failures and existing safeguards. For each failure, a risk priority number and criticality score were calculated. Failures were then ranked, with the highest scores representing the most critical failures to be targeted for redesign.ResultsA total of 28 steps were identified in the acute stroke diagnostic process. Iterative steps in the process include information gathering, clinical examination, interpretation of diagnostic test results, and reassessment. We found that failure to use existing screening scales to identify patients with large‐vessel occlusions early on in their ED course ranked highest. Failure to obtain an accurate history of the index event, failure to suspect acute stroke in triage, and failure to use established stroke screening tools at ED arrival to identify potential stroke patients were also highly ranked.ConclusionsOur study results highlight the critical importance of upstream steps in the acute stroke diagnostic process, particularly the use of existing tools to identify stroke patients who may be eligible for time‐sensitive treatments.