Nast Patricia A, Avidan Michael, Harris Carolyn B, Krauss Melissa J, Jacobsohn Eric, Petlin Ann, Dunagan W Claiborne, Fraser Victoria J
Department of Internal Medicine, Division of Infectious Diseases, Washington University School of Medicine, St Louis, MO 63110, USA.
J Thorac Cardiovasc Surg. 2005 Oct;130(4):1137. doi: 10.1016/j.jtcvs.2005.06.003.
The objective was to evaluate a new mechanism for reporting and classifying patient safety events to increase reporting and identify patient safety priorities.
A voluntary patient safety event reporting system accessible by all health care workers was implemented in the Cardiothoracic Intensive Care and Post Anesthesia Care Units. Information collected included patient identifiers; date, time, and location of report and event; type and description of event; and severity score. Narrative descriptions of events were analyzed and coded to describe when in the care process the event occurred, what occurred, and a causal classification of why the event occurred.
A total of 163 reports describing 157 events were received. These included 121 events reported from the intensive care unit (25.3 reported events per 1000 patient-days), a 3-fold increase compared with the preexisting on-line reporting system. A total of 113 reports (69%) came from nurses, 31 from physicians (19%), and 10 from other staff (6%). A majority of events (85, 54%) reached the patient but caused no harm. Multiple causes were identified for the majority of events. The most frequent causes were related to human factors (48%) and organizational factors (34%).
Health care workers were willing to use the patient safety event reporting system, which yielded a broad range of patient safety data. Patient safety events are multifaceted and often have multiple causal factors. Application of a causal classification model for patient safety event coding in the intensive care and preoperative and postoperative care units is feasible and facilitates local communication of important event-related information.
评估一种用于报告和分类患者安全事件的新机制，以增加报告数量并确定患者安全优先事项。
在心胸重症监护病房和麻醉后护理病房实施了所有医护人员均可访问的自愿性患者安全事件报告系统。收集的信息包括患者标识符；报告和事件的日期、时间和地点；事件类型和描述；以及严重程度评分。对事件的叙述性描述进行分析和编码，以描述事件在护理过程中的发生时间、发生了什么以及事件发生原因的因果分类。
共收到163份描述157起事件的报告。其中包括重症监护病房报告的121起事件（每1000患者日报告25.3起事件），与原有的在线报告系统相比增加了两倍。共有113份报告（69%）来自护士，31份来自医生（19%），10份来自其他工作人员（6%）。大多数事件（85起，54%）影响到了患者，但未造成伤害。大多数事件确定了多种原因。最常见的原因与人为因素（48%）和组织因素（34%）有关。
医护人员愿意使用患者安全事件报告系统，该系统产生了广泛的患者安全数据。患者安全事件是多方面的，通常有多种因果因素。在重症监护病房以及术前和术后护理病房应用患者安全事件编码的因果分类模型是可行的，并且有助于重要事件相关信息的本地交流。
