Retained Foreign Object Reduction and Mitigation (ReFORM)

减少和缓解残留异物 (ReFORM)

• 批准号: 10769545
• 负责人: Ken Catchpole
• 金额: $ 49.45万
• 依托单位: MEDICAL UNIVERSITY OF SOUTH CAROLINA
• 依托单位国家: 美国
• 财政年份: 2023
• 资助国家: 美国
• 起止时间: 2023-09-30 至 2027-08-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10769545
• 关键词: Retained; Foreign; Object; Reduction; Mitigation

ABSTRACT Retained Foreign Objects (RFOs) are one of the most well recognized and persistent patient safety problems, affecting between 3000 and 50,000 patients per year, with an 80% morbidity rate, The primary defense is the manual counting of items that enter and leave the surgical field (the “surgical count”), which can be unreliable, while technologies, policies and training still leave many potential opportunities for failure. We propose a Patient Safety Learning Lab that will explore the causes of and solutions to RFOs using a systems engineering approach. Our initial systems models will drive improved understanding of factors that influence successful and unsuccessful counting. Laboratory experiments in count grouping, including time pressures, distractors, and the role of technology will define and build an evidence for optimal count strategies. It will also be possible to identify multiple opportunities to enhance the perioperative count process prior to the commencement of the procedure; and the discovery of lost items in the case of a discrepant count. Finally, as RFO performance is affected by organizational work contexts, we will explore opportunities to enhance teamwork, and organizational learning processes post-event. This work will initiate the most fundamental reappraisal of the causes of and solutions to RFOs for more than 20 years.

摘要 保留异物(RFO)是最公认和最持久的患者安全问题之一， 每年影响3000到50,000名患者，发病率为80%，主要防御措施是 手动计数进入和离开外科领域的物品(手术计数)，这可能是不可靠的， 然而，技术、政策和培训仍然留下了许多潜在的失败机会。我们推荐一位病人 安全学习实验室，将使用系统工程方法探索RFO的原因和解决方案。 我们的初始系统模型将推动对影响成功和 计数不成功。计数分组的实验室实验，包括时间压力、分心物和 技术的作用将定义和建立最佳计数策略的证据。也有可能识别出 在手术开始前，有多种机会加强围手术期清点过程； 以及在计数不一致的情况下发现丢失的物品。最后，由于RFO性能受到以下因素的影响 在组织工作背景下，我们将探索加强团队合作和组织学习的机会 处理事件后处理。这项工作将启动最根本的重新评估的原因和解决方案 20多年的RFO。