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支持患者安全文化:病理学住院医师培训项目中由住院医师主导的患者安全事件审查

Supporting a culture of patient safety: Resident-led patient safety event reviews in a pathology residency training program.

作者信息

Tucker Catherine M, Jaffe Rebecca, Goldberg Allison

机构信息

Department of Pathology, Anatomy, and Cell Biology, Thomas Jefferson University Hospital, Philadelphia, PA, USA.

Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA.

出版信息

Acad Pathol. 2023 Feb 28;10(1):100069. doi: 10.1016/j.acpath.2023.100069. eCollection 2023 Jan-Mar.

Abstract

Patient safety is a critical component of quality patient care at any healthcare institution. In order to support a culture of patient safety, and in the context of a hospital-wide patient safety initiative at our institution, we have created and implemented a new patient safety curriculum within our training program. The curriculum is embedded in an introductory course for first-year residents, in which residents gain an understanding of the multifaceted role of the pathologist in patient care. The patient safety curriculum is a resident-centered event review process and includes 1) identification and reporting of a patient safety event, 2) event investigation and review, and 3) presentation of findings to the residency program including core faculty and safety champions for the consideration of implementation of the identified systems solution. Here we discuss the development of our patient safety curriculum, which was trialed over a series of seven event reviews conducted between January 2021 and June 2022. Resident involvement in patient safety event reporting and patient safety event review outcomes were measured. All event reviews conducted thus far have resulted in the implementation of the solutions discussed during event review presentations based on cause analysis and identification of strong action items. Ultimately this pilot will serve as the basis by which we implement a sustainable curriculum in our pathology residency training program centered on supporting a culture of patient safety, and in line with ACGME requirements.

摘要

患者安全是任何医疗机构优质患者护理的关键组成部分。为了支持患者安全文化,并在我们机构全院范围的患者安全倡议背景下,我们在培训项目中创建并实施了新的患者安全课程。该课程嵌入了面向一年级住院医师的入门课程,住院医师在此课程中了解病理学家在患者护理中的多方面作用。患者安全课程是以住院医师为中心的事件审查过程,包括:1)识别和报告患者安全事件;2)事件调查和审查;3)向住院医师培训项目(包括核心教员和安全倡导者)汇报调查结果,以供考虑实施已确定的系统解决方案。在此,我们讨论我们的患者安全课程的开发情况,该课程在2021年1月至2022年6月期间进行的一系列七次事件审查中进行了试验。对住院医师参与患者安全事件报告的情况以及患者安全事件审查结果进行了衡量。迄今为止进行的所有事件审查都导致根据原因分析和确定有力的行动项目,实施了在事件审查汇报中讨论的解决方案。最终,这个试点将作为我们在病理住院医师培训项目中实施可持续课程的基础,该课程以支持患者安全文化为中心,并符合美国研究生医学教育认证委员会(ACGME)的要求。

https://cdn.ncbi.nlm.nih.gov/pmc/blobs/8e96/9982285/8c5f7a8ccd80/gr1.jpg

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