Spread of Safety Interventions: Planning for Context

摘要 自1999年出版《人之常情》以来，可预防的伤害的减少一直很缓慢。而当 存在一些优秀的地方，在全国范围内推广经过验证的安全干预措施既不完整，也不 前后不一致。背景因素和执行因素被广泛认为是这一失败的根本原因。失败 推广和扩大经过验证的安全干预措施浪费资源并错失关键机会 以减少无法估量的病人伤害。作为这些挑战的结果，医院正在越来越多地加入质量 改进协作(QIC)。然而，QIC内部或外部的扩展和扩展通常遵循 “一刀切”的方法几乎不考虑上下文，因为：(1)关键的上下文因素是 在扩展之前通常不知道，以及(2)没有其他已知的扩展模型。我们有一个 有机会测试一个新的模型，使用‘忍者’作为模型。使用常规监控、实验室监控和 改变用药方案，肾毒性损伤被即时行动(忍者)减少 在一家医院，肾毒性药物相关的急性肾损伤(NTMx-AKI)减少了62%。在未来 多点研究发现，4家医院根本没有减少AKI，而5家医院降低了50%以上。医院有一家 NTMx-AKI的高速率通过两种不同的实现方法之一降低了它：(1)包括 药房冠军和多名药剂师致力于忍者或(2)确保忍者团队 领导者没有重大的相互竞争的要求，从而从实施中抽出时间。我们开发了一种 原型干预(“定制忍者”)，计划并解决特定的所需背景因素 (例如，药房冠军)，从成功实施的两条途径中选择一条。建议数 目标是：1.测试自定义忍者的可用性、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路径。2.了解上下文如何 和实施的便利性影响定制忍者医院之间AKI的变量减少，以及 与标准的忍者相比。3.评估忍者和自定义忍者实现的价值。建议 方法采用时间序列法、统计过程控制法、访谈法、调查法、回顾与前瞻性相结合的方法 成本评估和定性比较分析，它结合了代数和定性方法。这个 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儿童医院患者安全解决方案的框架内进行的，共有135多人参与 医院通力合作，消除对儿童可预防的伤害。拟议的研究测试了一个可扩展的 克服背景和实施障碍以更有效和高效地传播患者的方法 国家和国际安全干预措施。

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.