Ursprung R, Gray J E, Edwards W H, Horbar J D, Nickerson J, Plsek P, Shiono P H, Suresh G K, Goldmann D A
Children's Hospital Boston, Boston, MA, USA.
Qual Saf Health Care. 2005 Aug;14(4):284-9. doi: 10.1136/qshc.2004.012542.
Timely error detection including feedback to clinical staff is a prerequisite for focused improvement in patient safety. Real time auditing, the efficacy of which has been repeatedly demonstrated in industry, has not been used previously to evaluate patient safety. Methods successful at improving quality and safety in industry may provide avenues for improvement in patient safety.
Pilot study to determine the feasibility and utility of real time safety auditing during routine clinical work in an intensive care unit (ICU).
A 36 item patient safety checklist was developed via a modified Delphi technique. The checklist focused on errors associated with delays in care, equipment failure, diagnostic studies, information transfer and non-compliance with hospital policy. Safety audits were performed using the checklist during and after morning work rounds thrice weekly during the 5 week study period from January to March 2003.
A total of 338 errors were detected; 27 (75%) of the 36 items on the checklist detected >or=1 error. Diverse error types were found including unlabeled medication at the bedside (n = 31), ID band missing or in an inappropriate location (n = 70), inappropriate pulse oximeter alarm setting (n = 22), and delay in communication/information transfer that led to a delay in appropriate care (n = 4).
Real time safety audits performed during routine work can detect a broad range of errors. Significant safety problems were detected promptly, leading to rapid changes in policy and practice. Staff acceptance was facilitated by fostering a blame free "culture of patient safety" involving clinical personnel in detection of remediable gaps in performance, and limiting the burden of data collection.
及时发现错误并向临床工作人员反馈是重点改善患者安全的前提条件。实时审计在行业中其有效性已得到反复证明，但此前尚未用于评估患者安全。在行业中成功提高质量和安全性的方法可能为改善患者安全提供途径。
进行一项试点研究，以确定在重症监护病房（ICU）的日常临床工作中进行实时安全审计的可行性和实用性。
通过改良的德尔菲技术制定了一份包含36项内容的患者安全检查表。该检查表侧重于与护理延误、设备故障、诊断研究、信息传递以及不符合医院政策相关的错误。在2003年1月至3月为期5周的研究期间，每周三次在晨间查房期间及之后使用该检查表进行安全审计。
共检测到338处错误；检查表上36项中的27项（75%）检测到≥1处错误。发现了多种类型的错误，包括床边未贴标签的药物（n = 31）、身份识别带缺失或位置不当（n = 70）、脉搏血氧仪警报设置不当（n = 22）以及导致适当护理延误的沟通/信息传递延迟（n = 4）。
在日常工作中进行的实时安全审计能够检测到广泛的错误。重大安全问题被迅速发现，从而促使政策和实践迅速改变。通过营造一种无指责的“患者安全文化”，让临床人员参与发现可补救的绩效差距，并限制数据收集负担，促进了工作人员的接受度。
