Mira Jose Joaquin, Lorenzo Susana, Carrillo Irene, Ferrús Lena, Silvestre Carmen, Astier Pilar, Iglesias-Alonso Fuencisla, Maderuelo Jose Angel, Pérez-Pérez Pastora, Torijano Maria Luisa, Zavala Elena, Scott Susan D
Alicante-Sant Joan Health Department, Alicante, Spain.
Miguel Hernández University, Elche, Spain.
Int J Qual Health Care. 2017 Aug 1;29(4):450-460. doi: 10.1093/intqhc/mzx056.
To summarize the knowledge about the aftermath of adverse events (AEs) and develop a recommendation set to reduce their negative impact in patients, health professionals and organizations in contexts where there is no previous experiences and apology laws are not present.
Review studies published between 2000 and 2015, institutional websites and experts' opinions on patient safety.
Studies published and websites on open disclosure, and the second and third victims' phenomenon. Four Focus Groups participating 27 healthcare professionals.
Study characteristic and outcome data were abstracted by two authors and reviewed by the research team.
Fourteen publications and 16 websites were reviewed. The recommendations were structured around eight areas: (i) safety and organizational policies, (ii) patient care, (iii) proactive approach to preventing reoccurrence, (iv) supporting the clinician and healthcare team, (v) activation of resources to provide an appropriate response, (vi) informing patients and/or family members, (vii) incidents' analysis and (viii) protecting the reputation of health professionals and the organization.
Recommendations preventing aftermath of AEs have been identified. These have been designed for the hospital and the primary care settings; to cope with patient's emotions and for tacking the impact of AE in the second victim's colleagues. Its systematic use should help for the establishment of organizational action plans after an AE.
总结关于不良事件后果的知识,并制定一套建议,以减少在没有既往经验且不存在道歉法的情况下,不良事件对患者、医护人员和组织产生的负面影响。
回顾2000年至2015年间发表的研究、机构网站以及专家对患者安全的意见。
关于公开披露、“第二受害者”和“第三受害者”现象的已发表研究及网站。四个焦点小组,共有27名医护人员参与。
两名作者提取研究特征和结果数据,并由研究团队进行审核。
对14篇出版物和16个网站进行了综述。建议围绕八个领域构建:(i)安全与组织政策;(ii)患者护理;(iii)预防再次发生的积极方法;(iv)支持临床医生和医护团队;(v)激活资源以做出适当回应;(vi)告知患者和/或家属;(vii)事件分析;(viii)保护医护人员和组织的声誉。
已确定预防不良事件后果的建议。这些建议是为医院和基层医疗环境设计的,用于应对患者的情绪,并应对不良事件对“第二受害者”同事的影响。系统地使用这些建议应有助于在不良事件发生后制定组织行动计划。