ads to “near-misses,” adverse outcomes, and serious safety events (SSEs). The principles of an escalation culture have been used successfully in other highly reliable industries such as aviation, military, and manufacturing. We discuss here the introduction of a unique and compelling thought-process for developing an intraoperative escalation protocol that is specifically tailored for our institution. Inspired by a critical intraoperative event, this departmental protocol was developed based on an analysis of multispecialty literature and expert opinion to decrease the incidence of SSEs. It includes a stepwise approach and incorporates patient-specific information to guide team members who encounter dynamic clinical situations. The implementation of the protocol has facilitated continuous quality improvement through iterative education, improving communication, and enhancing decision-making. Concurrently, we have plans to incorporate technology and electronic decision support tools to enhance real-time communication, monitor performance, and foster a culture of safety....

中文翻译：

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麻醉学术中升级方案的基于过程的标准化


广告宣传到“未遂事故”、不良后果和严重安全事件 （SSE）。升级文化的原则已成功应用于其他高度可靠的行业，例如航空、军事和制造业。我们在这里讨论引入一个独特且引人注目的思维过程，以开发专门为我们机构量身定制的术中升级方案。受关键术中事件的启发，该部门方案是根据对多学科文献和专家意见的分析制定的，以降低 SSE 的发生率。它包括一种逐步方法，并结合患者特定信息来指导遇到动态临床情况的团队成员。该协议的实施通过迭代教育、改善沟通和加强决策，促进了持续的质量改进。同时，我们计划整合技术和电子决策支持工具，以增强实时通信、监控绩效并培养安全文化。