Patients as Partners in Learning from Unexpected Events
Patients as Partners in Learning from Unexpected Events
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DOI：
10.1111/1475-6773.12593
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发表时间：
2016-12-01
影响因子：
3.4
通讯作者：
Thomas, Eric J.
中科院分区：
文献类型：
--
作者：
Etchegaray, Jason M.;Ottosen, Madelene J.;Thomas, Eric J.
的重要性。患者安全专家认为，患者/家属应该参与不良事件的审查。然而，尚不清楚患者/家属对他们所经历的不良事件的原因了解多少。确定接受采访的患者/家属是否能够确定他们所经历的事件的至少一个促成因素。次要目标包括了解患者/家庭成员对不良事件的认识方式，患者/家庭成员确定的不同类型不良事件的影响因素类型，以及患者/家庭成员提供的解决影响因素的建议。我们采用半结构化访谈法对患者/家属进行访谈，以了解他们对不良事件发生原因的看法。不良事件发生于1991 - 2014年。参与者描述了在不同类型的医疗机构（即医院、流动设施/诊所和牙科诊所）发生的不良事件。我们采访了72名患者及其家属，他们每人都描述了一个独特的不良事件。资格要求是患者/家属说英语或西班牙语，并知道发生在他们或所爱的人身上的不良事件。临床试验的干预或观察性研究的暴露。N/A。主要结果和测量方法。主要结果是确定患者/家庭成员是否能够确定至少一个他们认为与他们所描述的不良事件相关的因素。每个参与者至少确定了一个影响因素，平均确定了3.67个影响因素。最常提到的影响因素是员工资格/知识（79%）、安全政策/程序（74%）和沟通（64%）。参与者仅通过个人观察（32%）、个人推理（11%）、个人研究（7%）、记录回顾（他们自己的医疗记录或他们在自己的调查中收到的报告；6%）和医生告诉他们的因素（5%）来了解影响因素。最后，患者/家庭成员能够针对我们所研究的9个影响因素提供建议。结论和相关性。患者/家属确定了与他们的不良事件相关的因素。鉴于保健组织可能不知道这些促成因素，因为大多数参与者表示他们没有参与分析过程，因此可能会错过组织向患者学习的机会。医疗机构应该就伤害他们的事件采访患者/家属，以帮助确保充分了解事件的原因。
Importance. Patient safety experts believe that patients/family members should be involved in adverse event review. However, it is unclear how aware patients/family members are about the causes of adverse events they experienced.Objective. To determine whether patients/family members interviewed could identify at least one contributing factor for the event they experienced. Secondary objectives included understanding the way patients/family members became aware of adverse events, the types of contributing factors patients/family members identified for different types of adverse events, and recommendations provided by patients/family members to address the contributing factors.Design. We interviewed patients/family members using semistructured interviews to understand their perceptions about why these adverse events occurred. The adverse events occurred between 1991 and 2014.Setting. Participants described adverse events that occurred in various types of health care organizations (i.e., hospitals, ambulatory facilities/clinics, and dental clinics).Participants. We interviewed 72 patients and family members who each described a unique adverse event. Eligibility requirements were that patients/family members spoke English or Spanish and were aware of an adverse event that happened to them or a loved one.Intervention(s) for Clinical Trials or Exposure(s) for Observational Studies. N/A.Main Outcome(s) and Measure(s). The main outcome was determining whether patients/family members could identify at least one contributing factor they perceived as related to the adverse event they described.Results. Each participant identified at least one contributing factor and on average identified 3.67 contributing factors for their event. The most frequently mentioned contributing factors were Staff Qualifications/Knowledge (79 percent), Safety Policies/Procedures (74 percent), and Communication (64 percent). Participants knew about the contributing factors from personal observation only (32 percent), personal reasoning (11 percent), personal research (7 percent), record review (either their own medical records or reports they received in their own investigation; 6 percent), and being told by a physician (5 percent). Finally, patients/family members were able to provide recommendations that address each of the nine contributing factors we examined.Conclusions and Relevance. Patients/family members identified contributing factors related to their adverse event. Given that these contributing factors might not be known to health care organizations because most participants stated that they were not involved in the analysis process, opportunities for organizational learning from patients are potentially being missed. Health care organizations should interview patients/family about the event that harmed them to help ensure a full understanding of the causes of the event.