Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, Yale New Haven Hospital, 333 Cedar St, P.O. Box 208063, New Haven, CT 06520-8063.
Semin Perinatol. 2017 Apr;41(3):156-160. doi: 10.1053/j.semperi.2017.03.004. Epub 2017 May 22.
The critical arm of improvement and change comes after events are identified and classified. Getting and making things right when things go wrong defines a successful safety program. This article reviews the important tasks that should be familiar to any team approaching a serious event on an obstetrics unit. Root cause analysis is a critical, but often misunderstood, tool for dissecting the contributing factors leading to an adverse event. Successful root cause analyses have a standardized approach that result in meaningful action plans. Disclosure to the patient of the event and error, if applicable, is a new concept that is gaining traction in medicine. The review of a structured disclosure program can help programs adopt a method that has successfully gained the trust of patients and families with very few complications. Second victim support through coordinated debriefing of the individuals and teams who worked during the event is a final important measure that is important to prevent burnout or identification and classification is just the beginning to having a systematic approach to adverse events. The critical arm to improvement and change comes in the analysis and response to these events, which includes root cause analysis, corrective action plans, error disclosure, and second victim support.
改进和变革的关键在于事件的识别和分类之后。当事情出错时，把事情做对并纠正错误，这定义了一个成功的安全计划。本文回顾了任何一个在产科病房处理严重事件的团队都应该熟悉的重要任务。根本原因分析是一种关键但经常被误解的工具，用于剖析导致不良事件的因素。成功的根本原因分析有一个标准化的方法，会产生有意义的行动计划。向患者披露事件和错误（如果适用）是医学领域一个新的概念，正在逐渐流行。审查结构化的披露计划可以帮助医院采用一种方法，这种方法已经成功赢得了患者和家属的信任，而且很少有并发症。通过协调参与事件的个人和团队的汇报，为“第二受害者”提供支持，是最后一个重要的措施，对于防止倦怠或识别至关重要，分类只是对不良事件进行系统处理的开始。改进和变革的关键在于对这些事件进行分析和响应，其中包括根本原因分析、纠正行动计划、错误披露和第二受害者支持。
