Wood Kathryn E, Nash David B
Thomas Jefferson University Hospital, 111 South 11th Street, Philadelphia, PA 19107, USA.
Am J Med Qual. 2005 Nov-Dec;20(6):297-303. doi: 10.1177/1062860605281850.
The magnitude of medical errors documented in the 1999 Institute of Medicine report "To Err Is Human" encouraged health care leaders across the country to evaluate and improve current systems of care. To aid in this effort, the authors recommended and provided guidelines for establishing state-based mandatory error-reporting systems. This repository for medical errors would allow experts to categorize, trend, and analyze data, generating institutional responsibility and increasing knowledge about medical mistakes. To be effective, these systems must employ efficient data collection methods, techniques for analysis, and feedback mechanisms. They must also engage institutional leaders in fostering a culture of safety and encourage multidisciplinary collaboration to learn from mistakes and improve microsystem-level processes. A review of current systems reveals extreme variation across states in each of these areas. However, initial successes do exist, suggesting the true potential of these systems and the need for continued evaluation as systems progress in future efforts.
1999年医学研究所报告《人皆有过》中记录的医疗差错规模，促使全国各地的医疗保健领导者评估并改进当前的医疗体系。为协助这一工作，作者们推荐并提供了建立基于州的强制性差错报告系统的指导方针。这个医疗差错资料库将使专家们能够对数据进行分类、追踪趋势和分析，明确机构责任，并增加对医疗失误的了解。要想有效，这些系统必须采用高效的数据收集方法、分析技术和反馈机制。它们还必须促使机构领导者营造安全文化，并鼓励多学科协作，以便从失误中吸取教训并改进微观系统层面的流程。对当前系统的审查显示，各州在这些领域的情况差异极大。然而，初步的成功确实存在，这表明了这些系统的真正潜力，以及随着系统在未来的发展而持续评估的必要性。
