Department of English and Communication, The International Research Centre for the Advancement of Health Communication, The Hong Kong Polytechnic University.
Health Commun. 2023 Oct;38(9):1770-1779. doi: 10.1080/10410236.2022.2031451. Epub 2022 Feb 24.
The paper explored the extent to which hospital appointed official root cause analysis (RCA) panels consider antecedent and proximal events when they investigate communication related sentinel events (CRSEs) in hospitals. It also explored which CRSEs are most common in the hospital setting in Hong Kong and the communication modes most commonly associated with CRSEs. The data consisted of Risk Alert and Annual Report on SEs issued by the Hong Kong Hospital Authority from October 2007 to September 2017. Over the period studied, there were 379 reported sentinel events (SEs). In 186 of these SEs we identified communication as a contributing factor. We examined the RCA panels' reports on contributing factors and subsequent recommendations in these 186 SEs and found that their recommendations only highlighted the proximal contributing factors and not antecedent factors that may be relevant. RCA panels most often recommended that communication should be enhanced or documentation improved. We propose that it is time to review the RCA process to recognize that many CRSEs may occur because of antecedent factors that result from the complex hospital organizational structure and its associated hierarchical culture. We suggest two ways forward, 1) applying a language and social psychology perspective to the investigations of CRSEs and, 2) the involvement of experts from different disciplines who can work with clinicians during RCA investigations.
本文探讨了医院指定的根本原因分析（RCA）小组在调查医院中与沟通相关的警戒事件（CRSE）时，考虑前因和近端事件的程度。它还探讨了在香港医院环境中最常见的 CRSE 以及与 CRSE 最常相关的沟通模式。数据包括香港医院管理局 2007 年 10 月至 2017 年 9 月发布的风险警示和年度 SE 报告。在所研究的期间内，报告了 379 起警戒事件（SE）。在这些 SE 中，我们确定有 186 起事件与沟通有关。我们检查了这 186 起 SE 中 RCA 小组关于促成因素及其后续建议的报告，发现他们的建议仅强调了近端促成因素，而没有强调可能相关的前因因素。RCA 小组最常建议应加强沟通或改进文件记录。我们提出，现在是时候审查 RCA 流程，以认识到许多 CRSE 可能是由于复杂的医院组织结构及其相关的等级文化所导致的前因因素造成的。我们提出了两种前进的方法，1）将语言和社会心理学视角应用于 CRSE 的调查，以及 2）涉及不同学科的专家，他们可以在 RCA 调查期间与临床医生合作。
