目的:本研究的目的是通过内部审计(IA)评估重症监护病房(CCU)零项目的实施情况。
方法:设计:实时观察安全性分析。编制了一份带有明确项目的问卷,以确保客观性。在IAS之后,与审计员进行了调查。
方法:ServizoGalegodeSaúde和Ribera-POVISA医院的11个CCU。
方法:由医疗,护理,对来自卫生领域的质量人员和34例患者进行了评估。
方法:符合质量标准(项目的≥60%),优势,需要改进的地方,审计师在IA中的权益,符合组织和项目。
结果:100%CCU符合质量标准。18.03%的项目由所有CCU完成。优势:员工激励,积极接受审计师,以及在某些CCU中使用计算机工具。需要改进的地方:气管内导管袖带压力控制自动系统的缺陷(符合CCU的9.1%),培训需求,沟通问题,并且不使用检查表(占报告的45.5%)。审计师发现IA非常有趣,19%的人建议改进组织和项目。
结论:所有CCU均符合先前商定的质量标准。确定了许多改进机会,并将其传达给已审计的CCU。为了更大的同质性和客观性,需要对先前商定的项目和定义进行审查。
OBJECTIVE: The objective of this study was to assess the implementation of Zero Projects in Critical Care Units (CCUs) through Internal Audits (IA).
METHODS: Design: Real-time observational safety analysis. A questionnaire was developed with defined items to ensure objectivity. After IAs, a survey was conducted with the auditors.
METHODS: 11 CCUs in hospitals of the Servizo Galego de Saúde and Ribera-POVISA.
METHODS: 24 auditors in 9 teams composed of medical, nursing, and quality personnel from health areas and 34 patients were assessed.
METHODS: Compliance with the quality standard (≥60% of items), strengths, areas for improvement, auditor\'s interest in IA, conformity with the organization and items.
RESULTS: 100% CCUs met the quality standard. 18.03% of items were fulfilled by all CCUs. Strengths: staff motivation, positive reception of auditors, and use of computer tools in some CCUs. Areas for improvement: deficit of automatic systems for controlling endotracheal tube cuff pressure (compliance rate in 9.1% of CCUs), training needs, communication issues, and not using checklists (45.5% of the reports). Auditors found IA very interesting, and 19% suggested improving organization and items.
CONCLUSIONS: All CCUs met the previously agreed-upon quality standard. Numerous improvement opportunities were identified and communicated to the audited CCUs. For greater homogeneity and objectivity, a review of previously agreed items and definitions is required.