Resilient Communication Systems: A Pediatric Patient Safety Learning Lab

项目总结/摘要 据估计，近十分之一的住院儿童可能会经历安全或伤害事件， 通信故障是导致患者安全和伤害事件的主要因素。2010年的一项研究估计， 低效的临床沟通每年浪费了美国医院120亿美元的临床医生， 时间和停留时间的增加。智能手机和安全文本等技术的引入 消息传递正在改变急性护理临床医生彼此之间的沟通方式、时间和内容。 开发基础设施来主动评估这些系统并建立其弹性至关重要。的 该项目的目标是创建一个新颖的，护士领导的儿科患者安全学习实验室，其目标是 重新设计跨专业人员（例如，儿科急症护理的（护士-医生）沟通工作系统 设置.学习实验室将由一个多学科团队组成，包括临床研究人员、人为因素 工程师，以人为本的设计专家，以及来自儿童医院的操作安全专家， 费城和宾夕法尼亚大学。我们还将让利益相关者参与进来，包括临床医生。 以及住院儿童的家庭，他们的护理经验可能会因临床医生如何 communicate.我们将使用系统工程方法（问题分析，设计，开发， 实施和评估），以主动评估跨专业沟通工作系统，流程， 和结果，以便在安全事件发生之前确定改进的机会。具体目标是 项目主要是（1）对跨行业沟通工作体系和工作进行问题分析 住院儿童护理中使用的流程;（2）设计和开发干预措施， 更有效，更有弹性的跨专业沟通工作系统;（3）实施和评估 临床环境中的干预措施，以衡量现实世界的影响。我们的学习实验室将由两个 框架、患者安全模型系统工程倡议和综合复原力 属性框架。这个学习实验室的产品将是一个跨专业的弹性系统， 沟通，一个可以积极适应面对预期和意外的变化， 在每年约250万例儿科住院治疗期间，维持所提供护理的安全性。

PROJECT SUMMARY/ABSTRACT Estimates suggest that nearly 1 in 10 hospitalized children may experience a safety or harm event, and communication breakdown is a leading contributor to patient safety and harm events. A 2010 study estimated that inefficient clinical communication cost US hospitals an estimated $12 billion annually in wasted clinician time and increased lengths of stay. The introduction of technologies such as smartphones and secure text messaging are transforming how, when, and what acute care clinicians communicate among each other. Developing an infrastructure to proactively evaluate these systems, and build their resilience, is critical. The goal of this project is to create a novel, nurse-led Pediatric Patient Safety Learning Lab with the objective of reengineering interprofessional (e.g., nurse-physician) communication work systems for pediatric acute care settings. The Learning Lab will consist of a multidisciplinary team of clinician-researchers, human factors engineers, human-centered design experts, and operational safety experts from Children's Hospital of Philadelphia and the University of Pennsylvania. We will also engage stakeholders, including bedside clinicians and families of hospitalized children, whose experience of care may be altered by changes to how clinicians communicate. We will use a systems engineering approach (Problem Analysis, Design, Development, Implement, and Evaluate) to proactively assess the interprofessional communication work system, processes, and outcomes, to identify opportunities for improvement before safety events occur. The Specific Aims of this project are to (1) Conduct a problem analysis of the interprofessional communication work system and work processes used in the care of hospitalized children; (2) Design and develop interventions to engineer a safer, more effective, and more resilient interprofessional communication work system; (3) Implement and evaluate the interventions in the clinical environment to gauge real-world impact. Our Learning Lab will be guided by two frameworks, the Systems Engineering Initiative for Patient Safety model and the Integrated Resilience Attributes Framework. The product of this Learning Lab will be a resilient system for interprofessional communication, one that can positively adapt in the face of anticipated and unanticipated changes and maintain the safety of care provided during the estimated 2.5 million pediatric hospitalizations each year.