Spread of Safety Interventions: Planning for Context

摘要 自1999年《人皆有错》出版以来，可预防的伤害的减少一直很缓慢。而 存在一些优秀的地方，在全国范围内推广经证实的安全干预措施既不完整， 前后矛盾背景和执行因素被广泛认为是这一失败的根本原因。失败 推广和扩大已证实的安全干预措施浪费资源并错失关键机会 以减少无法估量的患者伤害。由于这些挑战，医院越来越多地加入质量 改进协作（QIC）。然而，在合格中介公司内部或外部进行传播和扩大规模通常遵循以下原则： “一刀切”的方法，很少考虑上下文，因为：（1）关键的上下文因素是 在按比例放大之前通常是未知的，以及（2）没有其他已知的用于按比例放大的模型。我们有一个 有机会测试一个新的模式，使用'忍者'作为一个模型。使用常规监视，实验室监测， 药物治疗方案的变化，通过及时行动（NINJA）消除的肾毒性损伤减少 在一家医院，肾毒性药物相关急性肾损伤（NTMx-AKI）减少了62%。一项前瞻性 在多中心研究中，四家医院根本没有减少阿基，而五家医院减少了50%以上。的医院 高比率NTMx-AKI通过两种不同实现方法之一来降低它：（1）包括 药房冠军和多名药剂师在NINJA工作或（2）确保NINJA团队 领导者没有主要的竞争需求，这会从实施中抽出时间。我们开发了一个 原型干预（“定制忍者”），计划并解决特定的所需背景因素 (e.g.,药剂冠军），选择两种途径之一，以成功实施。拟议 目的是：1.测试定制忍者的可用性、可接受性和有效性，以计划和解决 具体的关键背景因素和两种不同的实施途径。2.了解上下文如何 和促进实施影响定制忍者医院中阿基的变量减少， 与标准NINJA相比。3.评估NINJA和CUSTOM NINJA实施的价值。提出 方法联合收割机结合时间序列、统计过程控制、访谈、调查、回顾和前瞻 成本评估和定性比较分析，将代数与定性方法相结合。的 经验丰富的研究团队对患者安全和实施有深入的了解，包括通过 QIC。这项研究是在QIC儿童医院的患者安全解决方案，超过135 医院共同努力，消除对儿童的可预防伤害。这项研究测试了一个可扩展的 克服背景和实施障碍的方法，以更有效和高效地传播患者 在国内和国际上采取安全措施。

ABSTRACT Since the publication of To Err is Human in 1999, reductions in preventable harm have been slow. While pockets of excellence exist, national spread of proven safety interventions has been both incomplete and inconsistent. Contextual and implementation factors are widely recognized as root causes of this failure. Failed spread and scale-up of proven safety interventions wastes resources and misses a critical opportunity to reduce incalculable patient harm. As a result of these challenges, hospitals are increasingly joining quality improvement collaboratives (QICs). However, spread and scale up, within or outside of QICs, typically follow a “one size fits all” approach that does little to account for context because: (1) the critical contextual factors are not usually known before scaling up and (2) there is no other known model for scale-up. We have an opportunity to test a new model, using ‘NINJA’ as a model. Using routine surveillance, lab monitoring, and changes in medication regimens, Nephrotoxic Injury Negated by Just-In-Time Action (NINJA) reduced nephrotoxic medication related Acute Kidney Injury (NTMx-AKI) by 62% at one hospital. In a prospective multisite study, four hospitals did not reduce AKI at all while five reduced it by over 50%. Hospitals with a high rate of NTMx-AKI reduced it through one of two different implementation methods: (1) Including a pharmacy champion and multiple pharmacists working on NINJA or (2) Ensuring the NINJA team leader has no major competing demands drawing time away from implementation. We developed a prototype intervention (“CUSTOM NINJA”) that plans for and addresses the specific required contextual factors (e.g., pharmacy champion), selecting ONE of the TWO pathways to successful implementation. The proposed aims are to: 1.Test the usability, acceptability, and effectiveness of CUSTOM NINJA to plan for and address specific critical contextual factors and TWO different pathways for implementation. 2. Understand how context and facilitation of implementation affect variable reduction in AKI among CUSTOM NINJA hospitals, and compared to standard NINJA. 3. Assess the value of NINJA and CUSTOM NINJA implementation. Proposed methods combine time-series, statistical process control, interviews, surveys, retrospective and prospective cost assessments, and qualitative comparative analysis, which combines algebra with qualitative methods. The experienced study team has deep knowledge of patient safety and implementation, including scale-up through QICs. This study is set within the QIC Children’s Hospitals Solutions for Patient Safety, with more than 135 hospitals working together to eliminate preventable harm to children. The proposed study tests a scalable approach to overcome contextual and implementation barriers to more effectively and efficiently spread patient safety interventions nationally and internationally.