Manalayil Jyothis, Kouranloo K, Horne L
Blackpool Victoria Hospital, Blackpool and Fylde NHS Foundation Trust, UK.
J Eur CME. 2021 Jan 19;10(1):1874643. doi: 10.1080/21614083.2021.1874643.
Patient safety incidents are any unintended or unexpected incidents which potentially could, or did, lead to harm to patients. Incident reports are crucial to improve patients' care and to identify further actions needed to prevent harm. A common view among the FY1 doctors in our local NHS Trust involved a fearful opinion surrounding being involved in clinical incidents. Significant anxiety in those situations prompted the need for a focus on the topic of "clinical incidents" during their induction to the Trust in two consecutive years of 2018 and 2019. A near-peer lecture series was delivered to new FY1 with qualitative pre- and post-lecture series feedbacks. Results from lecture series from two consecutive years showed all FY1 doctors agreed or strongly agreed that they had a good understanding of incidents following the lecture. Compared with their pre-course feedback, there was an increase of 6-fold (2018) and 8-fold (2019) in those that strongly agreed. Post-course, more than 90% of doctors reported that they would feel comfortable sharing with colleagues their involvement in an incident. In a growing culture of blame and litigation, it is important to address the harm associated with a blame-based culture. The process of investigating an incident has the potential to expose the areas of deficiency relating to an individual. Reducing stigma associated with incidents could theoretically reduce the second victim phenomenon. An open culture to incident reporting is a fundamental part of medical education and quality improvement. Encouraging this attitude amongst medical professionals and creating a supporting environment surrounding sharing of experiences will help to form a generation of doctors that see incident reporting in a positive light. Our model of lecture series could be utilised in other UK Foundation Programmes with the aim of enriching the FY1s' induction period.
患者安全事件是指任何可能或已经导致患者受到伤害的意外或非预期事件。事件报告对于改善患者护理以及确定预防伤害所需的进一步行动至关重要。在我们当地国民保健服务信托基金的第一年住院医生中,一种普遍的观点是对卷入临床事件存在恐惧看法。在这些情况下的严重焦虑促使在2018年和2019年连续两年他们入职信托基金期间需要关注“临床事件”这一主题。为新入职的第一年住院医生举办了一个近同伴讲座系列,并在讲座前后进行了定性反馈。连续两年讲座系列的结果显示,所有第一年住院医生都同意或强烈同意在讲座后他们对事件有了很好的理解。与课程前的反馈相比,强烈同意的人数增加了6倍(2018年)和8倍(2019年)。课程结束后,超过90%的医生报告说他们会愿意与同事分享自己卷入事件的情况。在日益增长的指责和诉讼文化中,解决与基于指责的文化相关的伤害很重要。调查事件的过程有可能暴露与个人相关的不足之处。从理论上讲,减少与事件相关的污名化可以减少“二次受害者”现象。对事件报告持开放态度是医学教育和质量改进的基本组成部分。在医学专业人员中鼓励这种态度,并围绕经验分享创造一个支持性环境,将有助于培养一代以积极眼光看待事件报告的医生。我们的讲座系列模式可用于英国其他基础课程,以丰富第一年住院医生的入职培训期。