Leape L L, Kabcenell A I, Gandhi T K, Carver P, Nolan T W, Berwick D M
Harvard School of Public Health, Boston, MA 02115, USA.
Jt Comm J Qual Improv. 2000 Jun;26(6):321-31. doi: 10.1016/s1070-3241(00)26026-4.
In January 1996, 38 hospitals and health care organizations (for a total of 40 hospitals) in the United States came together in an Institute for Healthcare Improvement (IHI; Boston) Breakthrough Series collaborative to reduce adverse drug events-injuries related to the use or nonuse of medications.
The participants were taught the Model for Improvement, a method for rapid-cycle change and evaluation, and were then coached on how to identify their own problem areas and develop changes in practice for rapid-cycle testing. These changes could be implementation of one or more known medication error prevention practices or new practices developed.
During a 15-month period the 40 hospitals conducted a total of 739 tests of changes. Process changes accounted for 63% of the cycles; the remainder consisted of preliminary data gathering, consensus-building, or education cycles. Eight types of changes were implemented by seven or more hospitals, with a success rate of 70%. These changes included non-punitive reporting, ensuring documentation of allergy information, standardizing medication administration times, and implementing chemotherapy protocols.
Success in making significant changes was associated with strong leadership, effective processes, and appropriate choice of intervention. Successful teams were able to define, clearly state, and relentlessly pursue their aims, and then chose practical interventions and moved early into changing a process. They did not spend months collecting data before beginning a change. Changes that were most successful were those that attempted to change processes, not people. Health care organizations committed to patient safety need not regard current performance limits as inevitable.
1996年1月，美国38家医院和医疗保健机构（共40家医院）共同参与了医疗改进研究所（IHI；波士顿）的突破系列协作项目，以减少药物不良事件——与用药或未用药相关的伤害。
参与者学习了改进模型，这是一种快速循环变革与评估的方法，随后接受指导，了解如何识别自身问题领域并制定实践变革以进行快速循环测试。这些变革可以是实施一种或多种已知的预防用药错误措施，也可以是开发新措施。
在15个月期间，40家医院共进行了739次变革测试。流程变革占循环次数的63%；其余包括初步数据收集、达成共识或教育循环。七种或更多医院实施了八种变革，成功率为70%。这些变革包括非惩罚性报告、确保过敏信息记录、规范用药时间以及实施化疗方案。
成功做出重大变革与强有力的领导、有效的流程以及恰当的干预选择相关。成功的团队能够明确界定、清晰阐述并坚定不移地追求其目标，然后选择切实可行的干预措施并尽早着手改变流程。他们在开始变革前没有花费数月时间收集数据。最成功的变革是那些试图改变流程而非人的变革。致力于患者安全的医疗保健机构不必将当前的绩效限制视为不可避免。
