Tjia Imelda, Rampersad Sally, Varughese Anna, Heitmiller Eugenie, Tyler Donald C, Lee Angela C, Hastings Laura A, Uejima Tetsu
From the Department of Pediatric Anesthesiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas; Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital; Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, Washington; Department of Anesthesiology, Cincinnati Children's Hospital Medical Center; Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, Ohio; Department of Anesthesiology and Critical Care Medicine and Pediatrics, Division of Pediatric Anesthesia, Johns Hopkins School of Medicine, Baltimore, Maryland; Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Division of Anesthesiology, Sedation and Perioperative Medicine, Children's National Medical Center, Washington, DC; Department of Anesthesiology, Keck School of Medicine, Children's Hospital Los Angeles, Los Angeles, California; and Department of Pediatric Anesthesia, Ann and Robert Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois.
Anesth Analg. 2014 Jul;119(1):122-136. doi: 10.1213/ANE.0000000000000266.
In 2006, the Quality and Safety Committee of the Society for Pediatric Anesthesia initiated a quality improvement project for the specialty of pediatric anesthesiology that ultimately resulted in the development of Wake Up Safe (WUS), a patient safety organization that maintains a registry of de-identified, serious adverse events. The ultimate goal of WUS is to implement change in processes of care that improve the quality and safety of anesthetic care provided to pediatric patients nationwide. Member institutions of WUS submit data regarding the types and numbers of anesthetics performed and information pertaining to serious adverse events. Before a member institution submits data for any serious adverse event, 3 anesthesiologists who were not involved in the event must analyze the event with a root cause analysis (RCA) to identify the causal factor(s). Because institutions across the country use many different RCA methods, WUS educated its members on RCA methods in an effort to standardize the analysis and evaluate each serious adverse event that is submitted. In this review, we summarize the background and development of this patient safety initiative, describe the standardized RCA method used by its members, demonstrate the use of this RCA method to analyze a serious event that was reported, and discuss the ways WUS plans to use the data to promote safer anesthetic practices for children.
2006年，小儿麻醉学会质量与安全委员会启动了一项针对小儿麻醉学专业的质量改进项目，最终促成了“安全苏醒”（WUS）的成立，这是一个患者安全组织，维护着一个经过去识别处理的严重不良事件登记册。WUS的最终目标是在护理流程中实施变革，以提高全国范围内为小儿患者提供的麻醉护理的质量和安全性。WUS的成员机构提交有关所实施麻醉的类型和数量的数据以及与严重不良事件相关的信息。在成员机构提交任何严重不良事件的数据之前，3名未参与该事件的麻醉医生必须通过根本原因分析（RCA）对该事件进行分析，以确定因果因素。由于全国各地的机构使用许多不同的RCA方法，WUS对其成员进行了RCA方法培训，以努力使分析标准化并评估所提交的每一起严重不良事件。在本综述中，我们总结了这项患者安全倡议的背景和发展情况，描述了其成员使用的标准化RCA方法，展示了使用该RCA方法对一起报告的严重事件进行分析的过程，并讨论了WUS计划利用这些数据促进更安全的小儿麻醉实践的方式。
