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关于参与不良事件的卫生专业人员同事的经验的定性研究。

Qualitative Study About the Experiences of Colleagues of Health Professionals Involved in an Adverse Event.

机构信息

From the Consorci Sanitari Integral, L'Hospitalet de Llobregat, Barcelona.

OSI Donostialdea. Donostia.

出版信息

J Patient Saf. 2021 Jan 1;17(1):36-43. doi: 10.1097/PTS.0000000000000309.

Abstract

OBJECTIVES

Identify what occurs among health-care providers (HCPs) after an adverse event (AE) and what colleagues could do to help them.

METHOD

A qualitative study with participation by physicians and nurses from hospitals and primary care facilities.

RESULTS

Fifteen HCPs and 12 health professionals with quality management responsibilities with between 8 and 30 years of experience participated; 15 (56%) were physicians (9 general practitioners, 3 surgeons, 2 intensivists, and 1 from an emergency unit), and 12 (44%) were nurses (5 worked in primary care and 7 in hospitals). There was consensus that second victims require support from colleagues and management; however, instead, many times they perceive rejection. They experience repetitive thoughts, fear, and loneliness. Formal channels of information favor the implementation of improvements. Health-care providers reported that information about measures for preventing a new adverse event is inaccessible, whereas management said that a change in behavior was necessary to promote a culture of safety. Common informal channels were the hallways and cafeteria. Reactions by colleagues of second victims were of surprise and to avoid involvement.

CONCLUSIONS

Organized plans and protocols about what to do to help HCPs after an AE are uncommon. Formal channels of information mitigate rumors and misinformation. Informal channels hinder learning from the experience and strengthening the culture of safety, and they encourage incidents to be hidden. Approaches that permit HCPs involved in an AE to speak about what has happened offer a positive response to their emotional needs.

摘要

目的

确定不良事件(AE)发生后医疗保健提供者(HCP)身上会发生什么,以及同事可以做些什么来帮助他们。

方法

一项定性研究,参与者为来自医院和初级保健机构的医生和护士。

结果

15 名 HCP 和 12 名具有质量管理职责的卫生专业人员,经验 8 至 30 年不等;15 名(56%)为医生(9 名全科医生、3 名外科医生、2 名重症监护医生和 1 名来自急诊室),12 名(44%)为护士(5 名在初级保健工作,7 名在医院工作)。大家一致认为,第二受害者需要同事和管理层的支持;然而,他们经常感到被拒绝。他们会反复思考、感到恐惧和孤独。正式的信息渠道有利于实施改进。医疗保健提供者报告说,关于预防新的不良事件的措施的信息无法获取,而管理层表示,必须改变行为以促进安全文化。常见的非正式渠道是走廊和自助餐厅。第二受害者的同事反应是惊讶和避免卷入。

结论

针对 AE 后如何帮助 HCP 制定有组织的计划和协议并不常见。正式的信息渠道可以减轻谣言和错误信息的传播。非正式渠道阻碍了从经验中学习和加强安全文化,并鼓励隐瞒事件。允许 AE 中涉及的 HCP 谈论所发生的事情的方法对他们的情感需求做出了积极的回应。

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