Quality improvement report - Learning from adverse incidents involving medical devices
Quality improvement report - Learning from adverse incidents involving medical devices
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DOI：
10.1136/bmj.325.7358.272
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发表时间：
2002-08-03
影响因子：
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通讯作者：
Ingram, P
中科院分区：
文献类型：
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作者：
Amoore, J;Ingram, P
人们认为NHS从事件中吸取教训的记录很差。尽管美国医疗器械管理局（Medical Devices Agency）做出了努力，发布了安全警告，但医疗器械的不良事件仍在继续发生，其中一些事件因器械故障、用户错误和组织问题而导致严重伤害或死亡。设计介绍关于支持性调查的反馈说明，旨在确定潜在因素、直接触发因素、原因背景和设置医疗物理部门提供设备管理服务的一个主要的NHS教学信托。改善的主要措施减少不良事件的重复和提高工作人员的能力，在使用设备。更改策略我们编制了一份意见摘要，以描述事件及设备的一般详情、总结调查结果（集中于潜在原因及即时触发因素）、描述员工应汲取的教训及积极行动。更改的效果我们已将意见摘要用于教学环节，并分发给病房联网护士。尽管是一种新的积极支持方法，但它鼓励了一种开放的报告文化。经验教训不良事件通常是由不同因素的结合引起的，但良好的做法可以防止错误成为事件。对事件的仔细分析揭示了多因素原因和有助于减少重复的良好做法。
Problem ne NHS is perceived to have a poor record of learning from incidents. Despite efforts of the Medical Devices Agency, which issues safety warnings, adverse incidents with medical devices continue to occur, some of which result in serious injury or death through device failures, user errors, and organisational problems.Design Introduction of feedback notes on a supportive investigation that seeks to determine latent factors, immediate triggers, causes, and positive actions taken by staff that minimised adverse consequences.Background and setting Medical physics department providing equipment management services in a major NHS teaching trust.Key measures for improvement Reduction in repetitions of adverse incidents and improved staff competency in using devices.Strategy for change A feedback note was developed to describe the incident and generic details of the equipment, summarise the investigation (focusing on latent causes and immediate triggers), and describe lessons to be learnt and positive actions by staff.Effects of change Feedback notes have been used in teaching sessions and given to ward link nurses. Despite being new, the positive supportive approach has encouraged an open reporting culture.Lessons learnt Adverse incidents are typically caused by alignment of different factors, but good practice can prevent errors becoming incidents. Careful analysis of incidents reveals both the multifactorial causes and the good practices that can help minimise repetitions.