PRA-Chicago Transplant Insight Study

描述(由申请人提供)：本申请使用概率风险评估(PRA)来估计移植供者/受者不匹配的频率。PRA已被证明有助于理解其他复杂的工作系统领域，如核电站，但它在卫生保健领域的应用是新的。这项研究的目标将是使用PRA来降低与移植不匹配相关的风险，并更广泛地确定如何将这一过程外推到其他卫生保健领域，并有助于提高患者的安全性。为此，提出了以下具体目标： 具体目标1：对移植供者/受者不匹配进行概率风险评估。 具体目标2：评估由此产生的概率风险评估对或有事件概率和模型变化的敏感性。 具体目标3：描述移植供者/受者不匹配评估的特征。 具体目标4：确定可降低受赠者/捐赠者不匹配风险的改进措施。 具体目标5：评估风险评估结果以及可能的过程和条件变化。 PRA模式将通过对移植工作的广泛实地分析来开发。首席调查员将为通常参与移植的所有工作人员之间的合作提供机会，而拥有超过25年PRA使用经验的分包商将提供有关PRA模型开发的所有方向。成果的传播和项目评估将通过利益攸关方讲习班完成。

DESCRIPTION (Provided by the Applicant): This application uses probabilistic risk assessment (PRA) to estimate the frequency of transplant donor/recipient mismatches. PRA has proven useful to understanding other complex work system domains, such as nuclear power plants, but its application in this area of health care is novel. The goal of this study will be to use PRA to mitigate risks associated with transplant mismatches, and more broadly, to determine how this process may be extrapolated to other areas of health care and contribute to improved patient safety. To this end, the following specific aims are proposed: Specific aim 1: Produce a probabilistic risk assessment of transplant donor/recipient mismatch. Specific aim 2: Evaluate the sensitivity of the resulting probabilistic risk assessment to contingent event probability and model changes. Specific aim 3: Characterize the transplant donor/recipient mismatch assessment. Specific aim 4: Identify improvements that could reduce the risk of recipient/donor mismatch. Specific aim 5: Evaluate the risk assessment results and possible process and condition changes. The PRA model will be developed through extensive field analysis of the work of transplants. The principal investigator will provide opportunities for collaboration among all staff typically involved in transplants, and the subcontractor, who has more than 25 years experience in use of PRA, will provide all direction regarding PRA model development. Dissemination of results and project evaluation will be accomplished through stakeholder workshops.