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模拟行动后回顾视频:支持从患者安全事件中进行社会和包容性学习的培训资源。

Videos of simulated after action reviews: a training resource to support social and inclusive learning from patient safety events.

机构信息

Graduate School of Healthcare Management, RCSI University of Medicine and Health Sciences, Dublin, Ireland

National Quality and Patient Safety Directorate, Office of the Chief Clinical Officer, Health Service Executive, Dublin, Ireland.

出版信息

BMJ Open Qual. 2023 Jul;12(3). doi: 10.1136/bmjoq-2023-002270.

DOI:10.1136/bmjoq-2023-002270
PMID:37553274
原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC10414102/
Abstract

Innovation in the education and training of healthcare staff is required to support complementary approaches to learning from patient safety and everyday events in healthcare. Debriefing is a commonly used learning tool in healthcare education but not in clinical practice. Little is known about how to implement debriefing as an approach to safety learning across a health system. After action review (AAR) is a debriefing approach designed to help groups come to a shared mental model about what happened, why it happened and to identify learning and improvement. This paper describes a digital-based implementation strategy adapted to the Irish healthcare system to promote AAR uptake. The digital strategy aims to assist implementation of national level incident management policies and was collaboratively developed by the RCSI University of Medicine and Health Sciences and the National Quality and Patient Safety Directorate of the Health Service Executive. During the COVID-19 pandemic, a well-established in-person AAR training programme was disrupted and this led to the development of a series of open access videos on AAR facilitation skills (which accompany the online version of this paper). These provide: (1) an introduction to the AAR facilitation process; (2) a simulation of a facilitated formal AAR; (3) techniques for handling challenging situations that may arise in an AAR and a (4) reflection on the benefits of the AAR process. These have the potential to be used widely to support learning from patient safety and everyday events including excellent care.

摘要

需要在医疗保健人员的教育和培训方面进行创新,以支持从患者安全和医疗保健日常事件中学习的补充方法。事后回顾 (AAR) 是一种常用于医疗保健教育但不在临床实践中使用的学习工具。对于如何将 AAR 作为一种安全学习方法在整个医疗系统中实施,人们知之甚少。行动后回顾 (AAR) 是一种事后回顾方法,旨在帮助团队就所发生的事情、为什么会发生以及识别学习和改进达成共同的心理模型。本文描述了一种适应爱尔兰医疗保健系统的基于数字的实施策略,以促进 AAR 的采用。该数字策略旨在协助实施国家层面的事件管理政策,由 RCSI 大学医学与健康科学学院和健康服务行政部门的国家质量和患者安全管理局共同开发。在 COVID-19 大流行期间,一个成熟的面对面 AAR 培训计划被打乱,这导致了一系列关于 AAR 促进技能的开放获取视频的开发(这些视频伴随本文的在线版本)。这些提供了:(1) AAR 促进过程简介;(2) 模拟正式的 AAR 促进;(3) 处理 AAR 中可能出现的棘手情况的技巧;以及 (4) 对 AAR 过程的好处的反思。这些有可能被广泛用于支持从患者安全和日常护理事件中学习,包括卓越的护理。

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The Irish National Adverse Event Study-2 (INAES-2): longitudinal trends in adverse event rates in the Irish healthcare system.爱尔兰不良事件研究-2(INAES-2):爱尔兰医疗体系中不良事件发生率的纵向趋势。
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