Vincent Charles A, Mboga Mwanamvua, Gathara David, Were Fred, Amalberti Rene, English Mike
Experimental Psychology, University of Oxford, Oxford, UK.
Health Services Unit, KEMRI-Wellcome Trust, Nairobi, Kenya.
Arch Dis Child. 2021 Apr;106(4):333-337. doi: 10.1136/archdischild-2020-320631. Epub 2021 Feb 11.
In a companion paper, we showed how local hospital leaders could assess systems and identify key safety concerns and targets for system improvement. In the present paper, we consider how these leaders might implement practical, low-cost interventions to improve safety. Our focus is on making immediate safety improvements both to directly improve patient care and as a foundation for advancing care in the longer-term. We describe a 'portfolio' approach to safety improvement in four broad categories: prioritising critical processes, such as checking drug doses; strengthening the overall system of care, for example, by introducing multiprofessional handovers; control of known risks, such as only using continuous positive airway pressure when appropriate conditions are met; and enhancing detection and response to hazardous situations, such as introducing brief team meetings to identify and respond to immediate threats and challenges. Local clinical leaders and managers face numerous challenges in delivering safe care but, if given sufficient support, they are nevertheless in a position to bring about major improvements. Skills in improving safety and quality should be recognised as equivalent to any other form of (sub)specialty training and as an essential element of any senior clinical or management role. National professional organisations need to promote appropriate education and provide coaching, mentorship and support to local leaders.
在一篇配套论文中,我们展示了地方医院领导如何评估系统并识别关键安全问题以及系统改进的目标。在本文中,我们思考这些领导如何实施切实可行且低成本的干预措施来提高安全性。我们的重点是立即改善安全状况,既直接改善患者护理,又作为长期推进护理工作的基础。我们描述了一种安全改进的“组合”方法,分为四大类:对关键流程进行优先级排序,如核对药物剂量;加强整体护理系统,例如通过引入多专业交接班;控制已知风险,如仅在满足适当条件时使用持续气道正压通气;以及加强对危险情况的检测和应对,如引入简短的团队会议以识别并应对即时威胁和挑战。地方临床领导和管理人员在提供安全护理方面面临诸多挑战,但如果得到足够的支持,他们仍有能力带来重大改进。改善安全和质量的技能应被视为等同于任何其他形式的(亚)专业培训,并且是任何高级临床或管理角色的基本要素。国家专业组织需要推广适当的教育,并为地方领导提供指导、辅导和支持。