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将重症监护病房安全报告系统与现有的事件报告系统相结合。

Integrating the intensive care unit safety reporting system with existing incident reporting systems.

作者信息

Thompson David A, Lubomski Lisa, Holzmueller Christine, Wu Albert, Morlock Laura, Fahey Maureen, Dickman Fern, Dorman Todd, Pronovost Peter

机构信息

Johns Hopkins University Schools of Medicine and Nursing, Baltimore, USA.

出版信息

Jt Comm J Qual Patient Saf. 2005 Oct;31(10):585-93. doi: 10.1016/s1553-7250(05)31076-2.

Abstract

BACKGROUND

Voluntary incident reporting systems that identify risks can be integrated into existing hospital reporting systems and can improve patient safety.

FINDINGS

A voluntary and anonymous Web-based intensive care unit safety reporting system (ICUSRS) was implemented in a cohort of intensive care units (ICUs). The reporting system was integrated into hospitals' reporting systems after the adverse event reporting structures were investigated. Reporting systems were classified as mandatory or voluntary and internal or external; the extent of formal training was identified and the trajectory of completed adverse events in the exisiting systems were tracked. Information from reported incidents was sent back monthly to the hospital ICUs through case discussions and a quarterly newsletter.

RESULTS

All seven hospitals had internal reporting systems and two also used external reporting systems. In general, the majority of incident reports were completed by registered nurses and were reported to the nursing chain of command. Many of the sites had little knowledge or understanding of their existing reporting systems.

CONCLUSION

Voluntary external reporting systems such as the ICUSRS hold promise for improving patient safety.

摘要

背景

能够识别风险的自愿性事件报告系统可整合到现有的医院报告系统中,从而提高患者安全。

研究结果

在一组重症监护病房(ICU)中实施了基于网络的自愿且匿名的重症监护病房安全报告系统(ICUSRS)。在对不良事件报告结构进行调查后,该报告系统被整合到医院的报告系统中。报告系统被分类为强制性或自愿性以及内部或外部;确定了正规培训的程度,并跟踪了现有系统中已完成不良事件的轨迹。通过病例讨论和季度通讯,每月将报告事件的信息反馈给医院的重症监护病房。

结果

所有七家医院都有内部报告系统,其中两家还使用外部报告系统。总体而言,大多数事件报告由注册护士完成,并报告给护理指挥链。许多机构对其现有的报告系统知之甚少或了解不足。

结论

诸如ICUSRS之类的自愿性外部报告系统有望提高患者安全。

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