Clinical Safety Research Unit, Centre for Patient Safety and Service Quality, Imperial College London, United Kingdom.
Ann Surg. 2012 Jun;255(6):1086-92. doi: 10.1097/SLA.0b013e31824f5f36.
To identify and prioritize hazards in surgical wards and recommend interventions.
Retrospective and prospective studies report the frequency and severity of surgical adverse events, but not in sufficient detail to allow interventions to be recommended in surgical wards.
Seventy hours of observations were used to record all activities occurring in surgical wards, and from these activities health care processes were derived. Fifty-nine patients and staff quantified the hazard associated with each health care process through a risk assessment survey. Modified health care failure mode and effects analysis was applied to the most hazardous of these processes to quantify the hazard of their associated failures. Cause analysis was applied to the most hazardous failures within analyzed processes. Interventions addressing the prioritized failures were recommended.
Surgical ward observations identified 81 activities. The risk assessment survey was used to quantify the hazard associated with 10 health care processes derived from these activities. The 5 most hazardous processes were prioritized for modified health care failure mode and effects analysis including hand hygiene, isolation of infection, vital signs, medication delivery, and hand off. Of 190 failures within these processes, 50 (26%) were considered hazardous and did not have effective control measures in place. The causes of these failures allowed interventions to be recommended.
Proactive risk assessments were used to systematically identify and prioritize hazards in surgical wards and allowed interventions to be recommended. These are practical tools that can determine where patient safety efforts should be targeted in clinical health care environments.
识别和确定外科病房的危害，并提出干预措施。
回顾性和前瞻性研究报告了外科不良事件的频率和严重程度，但没有详细到足以推荐外科病房干预措施的程度。
使用 70 小时的观察记录外科病房中发生的所有活动，并从这些活动中推导出医疗保健流程。59 名患者和工作人员通过风险评估调查对每个医疗保健流程相关的危害进行量化。对这些流程中最危险的流程应用改良医疗保健失效模式和效果分析，以量化相关失效的危害。对分析流程中最危险的失效进行原因分析。针对优先考虑的失效推荐干预措施。
外科病房观察共确定 81 项活动。风险评估调查用于量化从这些活动中推导出的 10 个医疗保健流程相关的危害。5 个最危险的流程被确定为改良医疗保健失效模式和效果分析的优先级，包括手卫生、感染隔离、生命体征、药物输送和交接。在这些流程中，190 个失效中有 50 个（26%）被认为是危险的，并且没有有效的控制措施。这些失效的原因允许提出干预措施。
前瞻性风险评估被用于系统地识别和确定外科病房的危害，并提出干预措施。这些实用工具可以确定患者安全工作应在临床医疗保健环境中的哪些方面进行重点关注。
