Observing sources of system resilience using in situ alarm simulations.
Observing sources of system resilience using in situ alarm simulations.
复制标题
使用现场警报模拟观察系统弹性的来源。
DOI：
10.1002/jhm.13217
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发表时间：
2023
影响因子：
2.6
通讯作者：
Rasooly,IritR
中科院分区：
文献类型：
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作者：
McLoone,Melissa;McNamara,Meghan;Jennings,MeganA;Stinson,HannahR;Luo,BrookeT;Ferro,Daria;Albanowski,Kimberly;Ruppel,Halley;Won,James;Bonafide,ChristopherP;Rasooly,IritR
警报疲劳(以及由此产生的警报无反应)威胁住院患者的安全。从历史上看，对患者安全的威胁，包括警报疲劳，都是使用安全I视角来评估的，分析罕见的事件，如未能对患者的严重警报做出反应。安全II方法要求从临床医生的日常适应中学习，以确保患者的安全。为了在警报系统中识别这种弹性来源，我们在2019年12月至2022年5月期间在一家三级儿科医院的内科/外科和重症监护病房进行了59次现场模拟严重低氧事件警报。响应时间、对环境的观察和模拟后的汇报访谈被记录下来。成功报警响应的四种主要方法被映射到患者安全系统工程倡议框架的域，以指导报警系统的设计和改进。
Alarm fatigue (and resultant alarm nonresponse) threatens the safety of hospitalized patients. Historically threats to patient safety, including alarm fatigue, have been evaluated using a Safety I perspective analyzing rare events such as failure to respond to patients' critical alarms. Safety II approaches call for learning from the everyday adaptations clinicians make to keep patients safe. To identify such sources of resilience in alarm systems, we conducted 59 in situ simulations of a critical hypoxemic‐event alarm in medical/surgical and intensive care units at a tertiary care pediatric hospital between December 2019 and May 2022. Response timing, observations of the environment, and postsimulation debrief interviews were captured. Four primary means of successful alarm responses were mapped to domains of Systems Engineering Initiative for Patient Safety framework to inform alarm system design and improvement.