Peterson Kimberly A, Rutherford Mary, Drvol Denise, Barkman Darlene, Phipps Amber R, Hales Roberta, Dawson Aaron, Stevens Laurie, Teman Susan, Teets Jeanette
Children's Hospital & Medical Center, Omaha, NE.
UCSF Benioff Children's Hospital Oakland, Oakland, CA.
Pediatr Qual Saf. 2019 Jun 27;4(4):e185. doi: 10.1097/pq9.0000000000000185. eCollection 2019 Jul-Aug.
Children's Hospitals' Solutions for Patient Safety (SPS) acknowledged a recommendation from the American Academy of Pediatrics to develop education programs on the communication of adverse events with patients and families. SPS set out to create a guide that would outline a standardized disclosure process and provide a training curriculum and tools so that providers would feel better prepared to have effective disclosure conversations.
SPS disclosure work began with the development of a project team made up of 9 network hospitals. The team utilized key driver diagrams and process maps to show the relationship between the project aims, key drivers, and specific interventions. The team developed a training curriculum, guide, and tools for each area of improvement. To ensure these were effective, they were tested using case studies and plan-do-study-act cycles.
One of the cohort hospitals piloted the curriculum and tools, training 48 physicians, nurses, executives, and other allied health professionals. Pretest to posttest scores improved from an average of 82.7% to 90.2%. Survey feedback was favorable with 100% of respondents noting that they strongly agree or agree that attending this educational activity increased or improved their competency, performance, and patient outcomes.
Initial testing suggests that the developed curriculum is empowering for frontline clinicians. Materials are available in an electronic format on the SPS external website. As member hospitals implement these materials, they will be evaluating learner satisfaction and provider usage. SPS will seek out feedback from these hospitals to further develop the materials and support clinicians.
儿童医院患者安全解决方案（SPS）认可了美国儿科学会的一项建议，即开发关于向患者及其家属通报不良事件的教育项目。SPS着手创建一份指南，该指南将概述标准化的披露流程，并提供培训课程和工具，以便医疗服务提供者能更好地准备好进行有效的披露对话。
SPS的披露工作始于组建一个由9家网络医院组成的项目团队。该团队利用关键驱动因素图和流程图来展示项目目标、关键驱动因素和具体干预措施之间的关系。该团队为每个改进领域开发了培训课程、指南和工具。为确保这些有效，通过案例研究和计划-执行-研究-改进循环对其进行了测试。
其中一家队列医院试用了该课程和工具，培训了48名医生、护士、管理人员和其他相关健康专业人员。前测到后测的分数从平均82.7%提高到了90.2%。调查反馈良好，100%的受访者表示他们强烈同意或同意参加这项教育活动提高或改善了他们的能力、表现和患者治疗效果。
初步测试表明，所开发的课程对一线临床医生有帮助。这些材料可在SPS外部网站上以电子格式获取。随着成员医院实施这些材料，他们将评估学习者的满意度和医疗服务提供者的使用情况。SPS将寻求这些医院的反馈，以进一步完善这些材料并支持临床医生。
