Kim Jeongeun, Bates David W
Seoul National University, College of Nursing, Research Institute of Nursing Science, 28 Yongon-dong, Chongno-gu, Seoul, 110-799, Seoul, Republic of Korea.
Int J Med Inform. 2006 Feb;75(2):148-55. doi: 10.1016/j.ijmedinf.2005.06.005. Epub 2005 Aug 10.
Recent data suggest that medical injuries, or adverse events, represent an important international problem, and that many are caused by errors. Spontaneous reporting is the main tool used to detect errors and adverse events in most countries, and reporting systems are believed to be important for improving patient safety. Increasingly, such reporting can be done using information systems, and information systems are widely used in Korea. However, few data are available regarding the use of electronic medical error reporting systems in Korea.
The objectives of this study were to investigate the present status of reporting system of Korean hospitals, and to compare the current status of medical error reporting systems with that of other health information sub systems.
The chairs of nursing departments of all 283 hospitals nationwide with more than 100 beds were surveyed using a structured questionnaire. The response rate was 35%. In addition, two reports on the national use of health information systems in Korea from 1999 and 2003 were analyzed.
Among reporting hospitals (n=99), medical errors were reported on paper in 75 hospitals (77%), verbally in 30 hospitals (30%), using word processing in 13 hospitals (13%), and using the hospital information system in only three hospitals (3%). In contrast, there was widespread and increasing use of health information technology (HIT) in areas such as medication administration, inpatient and outpatient order entry, and radiology.
While HIT is increasingly widely used in Korea in many areas, it is not being used for error reporting. Increasing the use of electronic reporting systems, and systemically evaluating the medical errors and adverse events reported, represent essential steps for reducing systemic errors and improving patient safety.
近期数据表明，医疗伤害或不良事件是一个重要的国际性问题，且许多是由差错导致的。在大多数国家，自发报告是用于发现差错和不良事件的主要工具，并且报告系统被认为对提高患者安全很重要。越来越多此类报告可通过信息系统完成，且信息系统在韩国被广泛使用。然而，关于韩国电子医疗差错报告系统的使用情况，可用数据很少。
本研究的目的是调查韩国医院报告系统的现状，并将医疗差错报告系统的现状与其他健康信息子系统的现状进行比较。
使用结构化问卷对全国283家床位超过100张的医院的护理部主任进行了调查。回复率为35%。此外，分析了1999年和2003年韩国全国健康信息系统使用情况的两份报告。
在报告医院（n = 99）中，75家医院（77%）以纸质形式报告医疗差错，30家医院（30%）通过口头报告，13家医院（13%）使用文字处理软件报告，只有3家医院（3%）使用医院信息系统报告。相比之下，健康信息技术（HIT）在诸如给药、住院和门诊医嘱录入以及放射学等领域得到广泛且日益增加的使用。
虽然HIT在韩国许多领域的使用越来越广泛，但它并未用于差错报告。增加电子报告系统的使用，并对报告的医疗差错和不良事件进行系统评估，是减少系统性差错和提高患者安全的关键步骤。
