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识别急诊科沟通中的薄弱环节。

Identifying vulnerabilities in communication in the emergency department.

作者信息

Redfern E, Brown R, Vincent C A

机构信息

Emergency Medicine, Bristol Royal Infirmary, Marlborough Street, Bristol BS2 8HW, UK.

出版信息

Emerg Med J. 2009 Sep;26(9):653-7. doi: 10.1136/emj.2008.065318.

Abstract

BACKGROUND

Communication in the emergency department (ED) is a complex process where failure can lead to poor patient care, loss of information, delays and inefficiency.

AIM

To describe the investigation of the communication processes within the ED, identify points of vulnerability and guide improvement strategies.

METHODS

The Failure Mode Effects Analysis (FMEA) technique was used to examine the process of communication between healthcare professionals involved in the care of individual patients during the time they spent in the ED.

RESULTS

A minimum of 19 communication events occurred per patient; all of these events were found to have failure modes which could compromise patient safety.

CONCLUSION

The communication process is unduly complex and the potential for breakdowns in communication is significant. There are multiple opportunities for error which may impact on patient care. Use of the FMEA allows members of the multidisciplinary team to uncover the problems within the system and to design countermeasures to improve safety and efficiency.

摘要

背景

急诊科的沟通是一个复杂的过程,沟通失败可能导致患者护理不佳、信息丢失、延误和效率低下。

目的

描述对急诊科内沟通流程的调查,识别脆弱点并指导改进策略。

方法

采用失效模式与效应分析(FMEA)技术,检查在急诊科就诊期间参与个体患者护理的医护人员之间的沟通流程。

结果

每位患者至少发生19次沟通事件;所有这些事件均发现存在可能危及患者安全的失效模式。

结论

沟通流程过于复杂,沟通中断的可能性很大。存在多种可能影响患者护理的出错机会。使用FMEA可使多学科团队成员发现系统内的问题,并设计对策以提高安全性和效率。

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