PDF(Pubmed)
Abstract：
UNASSIGNED: Patient handover is a crucial transition requiring a high level of coordination and communication. In the BC Children\'s Hospital (BCCH) pediatric intensive care unit (PICU), 10 adverse events stemming from issues that should have been addressed at the operating room (OR) to PICU handover were reported into the patient safety learning system (PSLS) within 1 year. We aimed to undertake a quality improvement project to increase adherence to a standardized OR to PICU handover process to 100% within a 6-month time frame. In doing so, the secondary aim was to reduce adverse events by 50% within the same 6-month period.
UNASSIGNED: The model for improvement and a Plan, Do, Study, Act method of quality improvement was used in this project. The adverse events were reviewed to identify root causes. The findings were reviewed by a multidisciplinary inter-departmental group comprised of members from surgery, anesthesia, and intensive care. Issues were batched into themes to address the most problematic parts of handover that were contributing to risk.
UNASSIGNED: A bedside education campaign was initiated to familiarize the team with an existing handover standard. The project team then formulated a new simplified visual handover tool with the mnemonic \"PATHQS\" where each letter denoted a step addressing a theme that had been noted in the pre-intervention work as contributing to adverse events.
UNASSIGNED: Adherence to standardized handover at 6 months improved from 69% to 92%. This improvement was sustained at 12 months and 3 years after the introduction of PATHQS. In addition, there were zero PSLS events relating to handover at 6 and 12 months, with only one filed by 36 months. Notably, staff self-reporting of safety concerns during handover reduced from 69% to 13% at 6 months and 0% at 3 years. The PATHQS tool created in this work also spread to six other units within the hospital as well as to one adult teaching hospital.
UNASSIGNED: A simplified handover tool built collaboratively between departments can improve the quality and adherence of OR to PICU handover and improve patient safety. Simplification makes it adaptable and applicable in many different healthcare settings.
UNASSIGNED: The model for improvement and a Plan, Do, Study, Act method of quality improvement was used in this project. The adverse events were reviewed to identify root causes. The findings were reviewed by a multidisciplinary inter-departmental group comprised of members from surgery, anesthesia, and intensive care. Issues were batched into themes to address the most problematic parts of handover that were contributing to risk.
UNASSIGNED: A bedside education campaign was initiated to familiarize the team with an existing handover standard. The project team then formulated a new simplified visual handover tool with the mnemonic \"PATHQS\" where each letter denoted a step addressing a theme that had been noted in the pre-intervention work as contributing to adverse events.
UNASSIGNED: Adherence to standardized handover at 6 months improved from 69% to 92%. This improvement was sustained at 12 months and 3 years after the introduction of PATHQS. In addition, there were zero PSLS events relating to handover at 6 and 12 months, with only one filed by 36 months. Notably, staff self-reporting of safety concerns during handover reduced from 69% to 13% at 6 months and 0% at 3 years. The PATHQS tool created in this work also spread to six other units within the hospital as well as to one adult teaching hospital.
UNASSIGNED: A simplified handover tool built collaboratively between departments can improve the quality and adherence of OR to PICU handover and improve patient safety. Simplification makes it adaptable and applicable in many different healthcare settings.
摘要：
■患者交接是一个关键的过渡，需要高水平的协调和沟通。在BC儿童医院（BCCH）儿科重症监护病房（PICU），在1年内，患者安全学习系统（PSLS）报告了10起不良事件，这些不良事件应在手术室（OR）到PICU移交中解决。我们的目标是开展质量改进项目，以在6个月的时间内将对标准OR到PICU移交过程的依从性提高到100％。在这样做的时候，次要目标是在相同的6个月内将不良事件减少50%.
■改进的模型和计划，Do,Study,本项目采用了质量改进的方法。对不良事件进行审查以确定根本原因。由外科成员组成的多学科跨部门小组对研究结果进行了审查，麻醉,和重症监护。问题被分成主题，以解决移交中造成风险的最有问题的部分。
■启动了床边教育活动，以使团队熟悉现有的移交标准。然后，项目团队使用助记符“PATHQS”制定了一个新的简化的视觉移交工具，其中每个字母都表示一个步骤，该步骤解决了干预前工作中指出的导致不良事件的主题。
■6个月时对标准化移交的依从性从69%提高到92%。这种改善在引入PATHQS后12个月和3年持续。此外,在6个月和12个月时，与移交有关的PSLS事件为零，只有一个在36个月前提交。值得注意的是,员工在交接期间对安全问题的自我报告从69%减少到6个月时的13%，3年时的0%。在这项工作中创建的PATHQS工具也扩展到医院内的其他六个单位以及一个成人教学医院。
■部门之间协作构建的简化移交工具可以提高OR对PICU移交的质量和依从性，并提高患者安全性。简化使其适应和适用于许多不同的医疗保健环境。
■改进的模型和计划，Do,Study,本项目采用了质量改进的方法。对不良事件进行审查以确定根本原因。由外科成员组成的多学科跨部门小组对研究结果进行了审查，麻醉,和重症监护。问题被分成主题，以解决移交中造成风险的最有问题的部分。
■启动了床边教育活动，以使团队熟悉现有的移交标准。然后，项目团队使用助记符“PATHQS”制定了一个新的简化的视觉移交工具，其中每个字母都表示一个步骤，该步骤解决了干预前工作中指出的导致不良事件的主题。
■6个月时对标准化移交的依从性从69%提高到92%。这种改善在引入PATHQS后12个月和3年持续。此外,在6个月和12个月时，与移交有关的PSLS事件为零，只有一个在36个月前提交。值得注意的是,员工在交接期间对安全问题的自我报告从69%减少到6个月时的13%，3年时的0%。在这项工作中创建的PATHQS工具也扩展到医院内的其他六个单位以及一个成人教学医院。
■部门之间协作构建的简化移交工具可以提高OR对PICU移交的质量和依从性，并提高患者安全性。简化使其适应和适用于许多不同的医疗保健环境。
