Lachman Peter, Linkson Lynette, Evans Trish, Clausen Henning, Hothi Daljit
Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.
BMJ Qual Saf. 2015 May;24(5):337-44. doi: 10.1136/bmjqs-2014-003795. Epub 2015 Mar 30.
The provision of safe care is complex and difficult to achieve. Awareness of what happens in real time is one of the ways to develop a safe system within a culture of safety. At Great Ormond Street Hospital, we developed and tested a tool specifically designed for patients and families to report harm, with the aim of raising awareness and opportunities for staff to continually improve and provide safe care. Over a 10-month period, we developed processes to report harm. We used the Model for Improvement and multiple Plan, Do, Study, Act cycles for testing. We measured changes using culture surveys as well as analysis of the reports. The tool was tested in different formats and moved from a provider centric to a person-centred tool analysed in real time. An independent person working with the families was best placed to support reporting. Immediate feedback to families was managed by senior staff, and provided the opportunity for clarification, transparency and apologies. Feedback to staff provided learning opportunities. Improvements in culture climate and staff reporting were noted in the short term. The integration of patient involvement in safety monitoring systems is essential to achieve safety. The high number of newly identified 'near-misses' and 'critical incidents' by families demonstrated an underestimation of potentially harmful events. This testing and introduction of a self-reporting, real-time bedside tool has led to active engagement with families and patients and raised situation awareness. We believe that this will lead to improved and safer care in the longer term.
提供安全护理是复杂且难以实现的。实时了解所发生的情况是在安全文化中建立安全系统的方法之一。在大奥蒙德街医院，我们开发并测试了一种专门为患者和家属设计的报告伤害的工具，目的是提高医护人员的意识，并为他们提供持续改进和提供安全护理的机会。在10个月的时间里，我们制定了报告伤害的流程。我们使用改进模型和多个计划-执行-研究-行动循环进行测试。我们通过文化调查以及对报告的分析来衡量变化。该工具以不同形式进行了测试，并从以提供者为中心的工具转变为实时分析的以人为本的工具。与家属合作的独立人员最适合支持报告工作。由高级工作人员向家属提供即时反馈，并提供澄清、透明和道歉的机会。向工作人员提供反馈则带来了学习机会。短期内注意到文化氛围和工作人员报告方面有所改善。让患者参与安全监测系统对于实现安全至关重要。家属新发现的大量“险些发生的事故”和“严重事件”表明，潜在有害事件被低估了。这种自我报告、实时床边工具的测试和引入促使家属和患者积极参与，并提高了态势感知。我们相信，从长远来看，这将带来更好、更安全的护理。
