Politi Ruth E, Mills Peter D, Zubkoff Lisa, Neily Julia
From the VA National Center for Patient Safety, Ann Arbor.
J Patient Saf. 2022 Oct 1;18(7):e1061-e1066. doi: 10.1097/PTS.0000000000001016. Epub 2022 Apr 30.
Although patient safety continues to be a priority in the U.S. healthcare system, delays in diagnosis, treatment, or surgery still led to adverse events for patients. The purpose of this study was to review root cause analysis (RCA) reports in the Veterans Health Administration to identify the root causes and contributing factors of delays in diagnosis, treatment, or surgery in an effort to prevent avoidable delays in future care.
The RCA reports from Veterans Health Administration hospitals from October 2016 through September 2019 were reviewed and the root causes and contributory factors were identified. These elements were coded by consensus and analyzed using descriptive statistics.
During the 3-year study period, 206 RCAs were identified and 163 were analyzed that were specific to delays in diagnosis, treatment, and surgery. The reports identified 24 delays in diagnosis, 117 delays in treatment, and 22 delays in surgery. Delays occurred most often in outpatient settings.
Results supported the need for standardization of care processes and procedures, improved communication between and within department personnel, and improved policies and procedures that will be followed as intended. By reviewing adverse events, root causes, and contributing factors identified by local RCA teams, strategies can be developed to reduce delays in diagnosis and treatment of patients and lead to safer care.
尽管患者安全在美国医疗系统中仍然是优先事项，但诊断、治疗或手术的延迟仍会给患者带来不良事件。本研究的目的是回顾退伍军人健康管理局的根本原因分析（RCA）报告，以确定诊断、治疗或手术延迟的根本原因和促成因素，从而努力防止未来医疗中可避免的延迟。
回顾了2016年10月至2019年9月退伍军人健康管理局医院的RCA报告，并确定了根本原因和促成因素。这些因素经共识编码后，使用描述性统计进行分析。
在3年的研究期间，共确定了206例RCA，其中163例针对诊断、治疗和手术延迟进行了分析。报告确定了24例诊断延迟、117例治疗延迟和22例手术延迟。延迟最常发生在门诊环境中。
结果支持对护理流程和程序进行标准化、改善部门间及部门内人员沟通以及改进将按预期遵循的政策和程序的必要性。通过回顾当地RCA团队确定的不良事件、根本原因和促成因素，可以制定策略来减少患者诊断和治疗的延迟，并实现更安全的护理。
