Keefer Patricia, Helms Lauren, Warrier Kavita, Vredeveld Jennifer, Burrows Heather, Orringer Kelly
Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Mich.; Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, Ann Arbor, Mich.; IHA Pediatrics, Canton, Mich.
Pediatr Qual Saf. 2017 Nov 8;2(6):e045. doi: 10.1097/pq9.0000000000000045. eCollection 2017 Nov-Dec.
Among the many modalities of error detection in academic pediatric hospitals, patient safety reporting is an important component, particularly for unexpected events. Residents recognize the importance of reporting but cite some barriers to doing so. A rubric was developed to guide resident reporting and streamline information gathering in patient safety reports. The rubric used the acronym SAFEST as a reminder to include 6 key elements:1. Staff involved in the incident.2. Actual event description.3. Follow-up initiated.4. Effect on patient.5. Standard of care described.6. To-do/suggestions for improvement.
This study was designed to determine if the addition of this educational rubric into a standard quality improvement curriculum improves the consistency of information documented in patient safety reports as a subset of a larger quality improvement project aimed at improving safety reporting.
A team of faculty members analyzed individual resident error reports for adherence to the 6 tenets of the SAFEST mnemonic.
From April to October of 2014, 2015, and 2016, a convenience sample of 131, 110, and 132 reports, respectively, were extracted and analyzed. For the rates of reporting "staff involved" and "standard of care," the differences over time were significant, both with values < 0.001. After training, residents were 2.2 times more likely to report on the "staff involved" in the error and 1.8 times more likely to report the "standard of care."
These results describe successful education on a rubric designed to improve the content of patient safety reports.
在学术性儿科医院众多的差错检测方式中，患者安全报告是一个重要组成部分，尤其是对于意外事件。住院医师认识到报告的重要性，但也指出了一些报告的障碍。制定了一个评分标准，以指导住院医师报告并简化患者安全报告中的信息收集。该评分标准使用首字母缩写词SAFEST来提醒包含6个关键要素：1. 事件涉及的工作人员。2. 实际事件描述。3. 已启动的后续跟进。4. 对患者的影响。5. 描述的护理标准。6. 待办事项/改进建议。
本研究旨在确定将此教育评分标准纳入标准质量改进课程是否能提高作为旨在改善安全报告的更大质量改进项目一部分的患者安全报告中记录信息的一致性。
一组教员分析了住院医师个人的差错报告，以确定是否符合SAFEST助记符的6个原则。
分别在2014年、2015年和2016年的4月至10月，抽取并分析了便利样本，报告数量分别为131份、110份和132份。对于“涉及的工作人员”和“护理标准”的报告率，随时间的差异具有显著性，P值均<0.001。培训后，住院医师报告差错中“涉及的工作人员”的可能性增加了2.2倍，报告“护理标准”的可能性增加了1.8倍。
这些结果表明，关于旨在改善患者安全报告内容的评分标准的教育取得了成功。
