Shaw R, Drever F, Hughes H, Osborn S, Williams S
National Patient Safety Agency, London, UK.
Qual Saf Health Care. 2005 Aug;14(4):279-83. doi: 10.1136/qshc.2004.010553.
To conduct a multicentre study on adverse event and near miss reporting in the NHS and to explore the feasibility of creating a national system for collecting these data.
Prospective voluntary reporting by staff with anonymised transfer of data was used by a national system to collect data from 18 NHS trusts.
Staff from 12 acute trusts, three mental health trusts, two ambulance trusts, and one primary care trust.
Number of incidents, date and time of incident, patient age and sex, clinical speciality, location, outcome, risk rating, type and description of incident.
A total of 28 998 incidents were reported including 11 766 (41%) slips, trips and falls, 2514 (9%) medication management incidents, 2429 (8%) resource issues, and 2164 (7%) treatment issues. 138 catastrophic and 260 major adverse outcomes were reported. Slips, trips and falls (n = 11 766) were the most common type of incident.
Voluntary reporting by staff when linked to a multicentre data collecting system can yield information on a large number of incidents. This provides support for the principle of creating a national IT system to collect and analyse incident data.
在英国国民医疗服务体系（NHS）中开展一项关于不良事件和险些失误报告的多中心研究，并探索创建一个收集这些数据的国家系统的可行性。
采用前瞻性自愿报告方式，工作人员进行匿名数据传输，由一个国家系统从18个NHS信托机构收集数据。
来自12个急症信托机构、3个精神健康信托机构、2个救护信托机构和1个初级保健信托机构的工作人员。
事件数量、事件日期和时间、患者年龄和性别、临床专科、地点、结果、风险评级、事件类型和描述。
共报告了28998起事件，其中包括11766起（41%）滑倒、绊倒和跌倒事件、2514起（9%）药物管理事件、2429起（8%）资源问题事件和2164起（7%）治疗问题事件。报告了138起灾难性和260起重大不良后果事件。滑倒、绊倒和跌倒事件（n = 11766）是最常见的事件类型。
工作人员的自愿报告与多中心数据收集系统相结合，可以产生大量事件的信息。这为创建一个国家信息技术系统来收集和分析事件数据的原则提供了支持。
