Kusano Aaron S, Nyflot Matthew J, Zeng Jing, Sponseller Patricia A, Ermoian Ralph, Jordan Loucille, Carlson Joshua, Novak Avrey, Kane Gabrielle, Ford Eric C
Department of Radiation Oncology, University of Washington School of Medicine, Seattle, Washington.
Department of Radiation Oncology, University of Washington School of Medicine, Seattle, Washington.
Pract Radiat Oncol. 2015 May-Jun;5(3):e229-e237. doi: 10.1016/j.prro.2014.07.002. Epub 2014 Aug 28.
Rigorous use of departmental incident learning is integral to improving patient safety and quality of care. The goal of this study was to quantify the impact of a high-volume, departmental incident learning system on patient safety culture.
A prospective, voluntary, electronic incident learning system was implemented in February 2012 with the intent of tracking near-miss/no-harm incidents. All incident reports were reviewed weekly by a multiprofessional team with regular department-wide feedback. Patient safety culture was measured at baseline with validated patient safety culture survey questions. A repeat survey was conducted after 1 and 2 years of departmental incident learning. Proportional changes were compared by χ(2) or Fisher exact test, where appropriate.
Between 2012 and 2014, a total of 1897 error/near-miss incidents were reported, representing an average of 1 near-miss report per patient treated. Reports were filed by a cross section of staff, with the majority of incidents reported by therapists, dosimetrists, and physicists. Survey response rates at baseline and 1 and 2 years were 78%, 80%, and 80%, respectively. Statistically significant and sustained improvements were noted in several safety metrics, including belief that the department was openly discussing ways to improve safety, the sense that reports were being used for safety improvement, and the sense that changes were being evaluated for effectiveness. None of the surveyed dimensions of patient safety culture worsened. Fewer punitive concerns were noted, with statistically significant decreases in the worry of embarrassment in front of colleagues and fear of getting colleagues in trouble.
A comprehensive incident learning system can identify many areas for improvement and is associated with significant and sustained improvements in patient safety culture. These data provide valuable guidance as incident learning systems become more widely used in radiation oncology.
严格运用科室事件学习对于提高患者安全和护理质量至关重要。本研究的目的是量化一个高容量的科室事件学习系统对患者安全文化的影响。
2012年2月实施了一个前瞻性、自愿性的电子事件学习系统，旨在追踪未遂事件/无伤害事件。所有事件报告每周由一个多专业团队进行审查，并定期向全科室反馈。在基线时使用经过验证的患者安全文化调查问卷问题来测量患者安全文化。在进行科室事件学习1年和2年后进行了重复调查。在适当情况下，通过χ²检验或Fisher精确检验比较比例变化。
2012年至2014年期间，共报告了1897起差错/未遂事件，平均每位接受治疗的患者有1起未遂事件报告。报告由不同部门的工作人员提交，其中大多数事件由治疗师、剂量师和物理学家报告。基线、1年和2年时的调查回复率分别为78%、80%和80%。在几个安全指标方面注意到了具有统计学意义的持续改善，包括相信科室正在公开讨论改善安全的方法、认为报告被用于安全改进的感觉以及认为正在对变化的有效性进行评估的感觉。患者安全文化的所有调查维度均未恶化。注意到惩罚性担忧减少，在同事面前感到尴尬的担忧以及担心给同事带来麻烦的恐惧在统计学上有显著下降。
一个全面的事件学习系统可以识别许多改进领域，并与患者安全文化的显著持续改善相关。随着事件学习系统在放射肿瘤学中得到更广泛的应用，这些数据提供了有价值的指导。
