Error Identification Between Health Systems—A Patient Safety Blind Spot

卫生系统之间的错误识别——患者安全盲点

• 批准号: 9768963
• 负责人: LESLY A DOSSETT
• 金额: $ 15.53万
• 依托单位: UNIVERSITY OF MICHIGAN AT ANN ARBOR
• 依托单位国家: 美国
• 财政年份: 2018
• 资助国家: 美国
• 起止时间: 2018-09-01 至 2022-08-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9768963
• 关键词: Error; Identification; Between; Health; Systems

PROJECT SUMMARY Preventable medical errors represent a major public health problem. To prevent future errors, improve disclosure, and mitigate malpractice risks, organizations have adopted strategies for early transparent communication and emphasized quality improvement through peer review. These principles are incorporated into the AHRQ Communication and Optimal Resolution (CANDOR) Toolkit, which facilitates 1) transparent communication, 2) error prevention, and 3) achieving optimal resolution with patients and families. What physician's should do when they discover another physician's error is less clear. Application of the CANDOR process may be particularly complex when the discovering and responsible physicians practice in different facilities. Without clear expectations or mechanisms for disclosure and feedback on the part of the discovering provider, it is uncertain to what extent and in what way these errors are being communicated with patients or responsible providers. Further, known barriers to disclosure and reporting one's own error may not be relevant or replaced by other unknown barriers when considering transparent communication regarding another physician's error. Providing a communication and resolution strategy applicable to errors discovered between physicians and facilities would help address this current blind spot in the patient safety and quality improvement movement. We will investigate these questions through a series of studies engaging stakeholders. This research will be the first to develop strategies to improve physician-to-physician communication over sensitive patient scenarios representing complex ethical and professional challenges for many physicians. Furthermore, the research project, multidisciplinary mentorship team, and unparalleled research environment are ideally suited to address the career goals and educational needs of the candidate, Lesly Dossett, MD, MPH. The proposal includes a detailed educational plan with training that will be essential for successful completion of this research and for Dr. Dossett's career development. The training includes mentored research and graduate level courses in implementation science. This career development award will lay the groundwork for Dr. Dossett to perform ongoing, innovative health services research, and to become an independent investigator.

项目总结 可预防的医疗差错是一个重大的公共卫生问题。为防止未来出现错误，请改进 为了减少信息披露和减少舞弊风险，各组织已经采取了及早透明的战略 他强调通过同行评议来提高质量。这些原则被纳入其中 进入AHRQ通信和最佳分辨率(CARTOR)工具包，这有助于1)透明 沟通，2)错误预防，以及3)实现与患者和家属的最佳解决方案。 当医生发现另一位医生的错误时，他们应该做什么还不太清楚。适用于 坦率的过程可能特别复杂，当发现和负责任的医生在 不同的设施。没有明确的期望或披露和反馈的机制 发现提供商时，不确定这些错误在多大程度上以何种方式进行通信 患者或负责任的提供者。此外，披露和报告自己的错误的已知障碍可能 在考虑透明沟通时不相关或被其他未知障碍取代 关于另一位医生的错误。提供适用于错误的沟通和解决策略 医生和设施之间的发现将有助于解决目前患者安全方面的盲点 和质量改进运动。我们将通过一系列研究来调查这些问题 让利益相关者参与进来。 这项研究将是第一次制定策略，以改善医生与医生之间的沟通 敏感的患者场景代表着许多医生面临的复杂的道德和专业挑战。 此外，研究项目、多学科导师团队和无与伦比的研究环境 非常适合满足候选人Lesly Dossett医学博士的职业目标和教育需求， 时速。该提案包括一项详细的教育计划，以及对成功至关重要的培训。 这项研究的完成和多塞特博士的职业发展。培训包括被指导 实施科学方面的研究和研究生水平课程。这一职业发展奖将奠定 为Dossett博士进行持续的、创新的健康服务研究并成为 独立调查员。