Grading recommendations for enhanced patient safety in sentinel event analysis: the recommendation improvement matrix.

Autor:	Bos K; Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands., van der Laan MJ; Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands., Groeneweg J; Delft University of Technology, TU Delft, Delft, The Netherlands.; University of Leiden, Leiden, The Netherlands., Kamps GJ; Intergo International Centre for Safety Ergonomics and Human Factors, Amersfoort, The Netherlands., Legemate DA; Department of Surgery, Amsterdam UMC Location AMC, Amsterdam, The Netherlands., Leistikow I; Erasmus University Rotterdam, Rotterdam, The Netherlands., Dongelmans DA; Department of Intensive Care Medicine, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands d.a.dongelmans@amsterdamumc.nl.; Amsterdam Public Health Research Institute, Amsterdam, The Netherlands.
Jazyk:	angličtina
Zdroj:	BMJ open quality [BMJ Open Qual] 2024 Apr 16; Vol. 13 (2). Date of Electronic Publication: 2024 Apr 16.
DOI:	10.1136/bmjoq-2023-002592
Abstrakt:	Objectives: The goal of sentinel event (SE) analysis is to prevent recurrence. However, the rate of SEs has remained constant over the past years. Research suggests this is in part due to the quality of recommendations. Currently, standards for the selection of recommendations are lacking. Developing a method to grade recommendations could help in both designing and selecting interventions most likely to improve patient safety. The aim of this study was to (1) develop a user-friendly method to grade recommendations and (2) assess its applicability in a large series of Dutch perioperative SE analysis reports. Methods: Based on two grading methods, we developed the recommendation improvement matrix (RIM). Applicability was assessed by analysing all Dutch perioperative SE reports over a 12-month period. After which interobserver agreement was studied. Results: In the RIM, two elements are crucial: whether the recommendation intervenes before or after an SE and whether it eliminates or controls the hazard. Applicability was evaluated in 115 analysis reports, encompassing 161 recommendations. Recommendation quality varied from the highest, category A, to the lowest, category D, with category A accounting for 44%, category B for 35%, category C for 2% and category D for 19% of recommendations. There was a fair interobserver agreement. Conclusion: The RIM can be used to grade recommendations in SE analysis and could possibly help in both designing and selecting interventions. It is relatively simple, user-friendly and has the potential to improve patient safety. The RIM can help formulate effective and sustainable recommendations, a second key objective of the RIM is to foster and facilitate constructive dialogue among those responsible for patient safety. Competing Interests: Competing interests: None declared. (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)
Databáze:	MEDLINE
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