Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
BMJ Qual Saf. 2012 Oct;21(10):855-62. doi: 10.1136/bmjqs-2011-000133. Epub 2011 Nov 7.
One in seven pages are sent to the wrong physician and may result in unnecessary delays that potentially threaten patient safety. The authors aimed to implement a new team-based paging process to reduce pages sent to the wrong physician.
The authors redesigned the paging process on general internal medicine (GIM) wards at a Canadian academic medical centre by implementing a standardised team-based paging process (pages directed to one physician responsible for receiving pages on behalf of the entire physician team) using rapid-cycle change methods. The authors evaluated the intervention using a controlled before-after study design by measuring pages sent to the wrong physician before and after implementation of the redesigned paging process.
Pages sent to the wrong physician from the GIM (intervention) wards decreased from 14% to 3% (11% reduction), while pages sent to the wrong physician from control wards fell from 13% to 7% (6% reduction). The difference between the intervention wards and the control wards was significant (5% greater reduction in the intervention group compared with the control group, p=0.008). Nurses were more satisfied with team-based paging than the existing paging process. Team-based paging may, however, introduce changes in communication workflow that lead to increased paging interruptions for certain members of the physician team.
The authors successfully redesigned the hospital's paging process to decrease pages sent to the wrong physician. They recommend that the frequency of pages sent to the wrong physician is measured and changes be implemented to paging processes to reduce this error.
每七页中就有一页会被发送给错误的医生，这可能导致不必要的延误，从而对患者安全造成潜在威胁。作者旨在实施新的基于团队的呼叫流程，以减少发送给错误医生的呼叫。
作者通过使用快速循环变更方法，在加拿大一家学术医疗中心的普通内科（GIM）病房重新设计了呼叫流程，实施了标准化的基于团队的呼叫流程（呼叫被定向到一位负责接收整个医生团队呼叫的医生）。作者通过在实施重新设计的呼叫流程前后进行对照前后研究设计来评估干预措施，通过测量在实施重新设计的呼叫流程前后发送给错误医生的呼叫数量来进行评估。
从 GIM（干预）病房发送给错误医生的呼叫从 14%降至 3%（减少 11%），而从对照病房发送给错误医生的呼叫从 13%降至 7%（减少 6%）。干预病房与对照病房之间的差异具有统计学意义（干预组比对照组减少 5%，p=0.008）。护士对基于团队的呼叫比现有呼叫流程更满意。然而，基于团队的呼叫可能会改变沟通工作流程，从而导致医生团队的某些成员接到更多的呼叫中断。
作者成功地重新设计了医院的呼叫流程，以减少发送给错误医生的呼叫数量。他们建议测量发送给错误医生的呼叫频率，并对呼叫流程进行更改，以减少这种错误。
