Identifying and categorising patient safety hazards in cardiovascular operating rooms using an interdisciplinary approach: a multisite study

被引：91

作者：

Gurses, Ayse P. ^{[1
,2
,3
,4
]}

Kim, George ^{[1
,2
,3
]}

Martinez, Elizabeth A. ^{[5
]}

Marsteller, Jill ^{[1
,2
,4
,6
]}

Bauer, Laura ^{[2
]}

Lubomski, Lisa H. ^{[1
,2
]}

Pronovost, Peter J. ^{[1
,2
,4
,7
,8
]}

Thompson, David ^{[1
,2
,7
]}

机构：

[1] Johns Hopkins Univ, Sch Med, Armstrong Inst Patient Safety & Qual, Baltimore, MD USA

[2] Johns Hopkins Univ, Sch Med, Dept Anesthesiol & Crit Care Med, Baltimore, MD 21205 USA

[3] Johns Hopkins Univ, Sch Med, Div Hlth Sci Informat, Baltimore, MD USA

[4] Johns Hopkins Univ, Dept Hlth Policy & Management, Bloomberg Sch Publ Hlth, Baltimore, MD 21218 USA

[5] Harvard Univ, Massachusetts Gen Hosp, Dept Anesthesia Crit Care & Pain Med, Boston, MA 02115 USA

[6] Johns Hopkins Univ, Ctr Hlth Serv & Outcomes Res, Bloomberg Sch Publ Hlth, Baltimore, MD USA

[7] Johns Hopkins Univ, Sch Nursing, Baltimore, MD USA

[8] Johns Hopkins Univ, Sch Med, Dept Surg, Baltimore, MD 21205 USA

来源：

BMJ QUALITY & SAFETY | 2012年 / 21卷 / 10期

基金：

美国国家卫生研究院; 美国医疗保健研究与质量局;

关键词：

CARDIAC-SURGERY; ADVERSE EVENTS; CARE; ERRORS; INTERVENTION; FAILURES; SOCIETY; QUALITY; RISK;

D O I：

10.1136/bmjqs-2011-000625

中图分类号：

R19 [保健组织与事业（卫生事业管理）];

学科分类号：

摘要：

Background: Cardiac surgery is a complex, high-risk procedure with potential vulnerabilities for patient safety. The evidence base describing safety hazards in the cardiovascular operating room is underdeveloped but is essential to guide future safety improvement efforts. Objective: To identify and categorise hazards (anything that has the potential to cause a preventable adverse patient safety event) in the cardiovascular operating room. Methods: An interdisciplinary team of researchers used prospective methods, including direct observations, contextual inquiry and photographs to collect hazard data pertaining to the cardiac surgery perioperative period, which started immediately before the patient was transferred to the operating room and ended immediately after patient handoff to the post-anaesthesia/intensive care unit. Data were collected between February and September 2008 in five hospitals. An interdisciplinary approach that included a human factors and systems engineering framework was used to guide the study. Results: Twenty cardiac surgeries including the corresponding handoff processes from operating room to post-anaesthesia/intensive care unit were observed. A total of 58 categories of hazards related to care providers (eg, practice variations), tasks (eg, high workload), tools and technologies (eg, poor usability), physical environment (eg, cluttered workspace), organisation (eg, hierarchical culture) and processes (eg, non-compliance with guidelines) were identified. Discussion: Hazards in cardiac surgery services are ubiquitous, indicating numerous opportunities to improve safety. Future efforts should focus on creating a stronger culture of safety in the cardiovascular operating room, increasing compliance with evidence-based infection control practices, improving communication and teamwork, and developing a partnership among all stakeholders to improve the design of tools and technologies.

引用

页码：810 / 818

页数：9

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