Failure to Rescure-Patient Safety Learning Lab (FTR-PSLL)

 描述(申请人提供)：尽管在医疗保健领域从事了十多年的安全工作，但可预防事件造成的伤害和死亡仍然是美国第三大死亡原因。[1]不同医院的死亡率差异很大，表明有很大的改善机会。几十年来，患者安全工作的重点一直是预防并发症，以努力最终降低死亡率。然而，这些努力没有产生重大影响，人们越来越认识到，医院的高死亡率和低死亡率 区别与其说是他们的并发症发生率，不如说是他们在临床恶化的早期阶段一旦发生并发症就如何成功地识别和管理这些并发症。因此，最大限度地减少“抢救失败”(即重大并发症后死亡)对于降低住院患者的死亡率至关重要。 成功的抢救取决于及早识别和及时处理发生的严重并发症，这需要了解所有涉及的因素和最重要的因素。我们建议建立FTR患者安全学习实验室，专注于创建理想的医院救援系统。重点将放在对不可预防的并发症的早期“上游”识别和管理上。研究将针对在支持早期发现并发症的理想风险评估/监测背后的技术因素以及在有效管理这些并发症方面支持理想的个人和团队反应的人为因素方面的差距。一种新颖的翻译方法将被用来快速支持可靠的早期救援。最终，理想的综合救援系统将具有巨大的潜力，可以降低目前与FTR相关的死亡率和危害。

 DESCRIPTION (provided by applicant): Despite over a decade of safety work in healthcare, injury and death due to preventable events remain the third leading cause of death in the U.S. [1] Wide variation in mortality rates across hospitals suggest substantial opportunities for improvement. Several decades of patient safety work have been focused on preventing complications in an effort to ultimately reduce mortality. However, these efforts have not had a significant impact and there is growing recognition that high mortality and low mortality hospitals are distinguished less by their complication rates than by how successfully they recognize and manage complications once they occur during the early period of clinical deterioration. Thus, minimizing "failure to rescue" (i.e., death following a major complication) FTR) is critical to reducing mortality in hospitalized patients. Successful rescue hinges on early recognition and timely management of serious complications once they occur, which requires understanding all of the factors involved and which are most important. We propose to establish a FTR Patient Safety Learning Lab that is focused on creating the ideal hospital rescue system. The focus will be on early "upstream" recognition and management of non-preventable complications. Studies will target gaps in understanding the technology factors behind ideal risk assessment/surveillance supporting early detection of complications and the human factor that support the ideal individual and team response in effectively managing these complications. A novel translation approach will be used to rapidly support reliable "early" rescue. Ultimately, the ideal Integrated Rescue System will have tremendous potential to reduce both the mortality and harm currently associated with FTR.