英国一家急诊科的事件报告。
Incident reporting in one UK accident and emergency department.
作者信息
Tighe Catherine M, Woloshynowych Maria, Brown Ruth, Wears Bob, Vincent Charles
机构信息
Clinical Safety Research Unit, Department of Biosurgery and Surgical Technology, Imperial College, St. Mary's Campus, Praed Street, London W2 1NY, United Kingdom.
出版信息
Accid Emerg Nurs. 2006 Jan;14(1):27-37. doi: 10.1016/j.aaen.2005.10.001.
Greater focus is needed on improving patient safety in modern healthcare systems and the first step to achieving this is to reliably identify the safety issues arising in healthcare. Research has shown the accident and emergency (A&E) department to be a particularly problematic environment where safety is a concern due to various factors, such as the range, nature and urgency of presenting conditions and the high turnover of patients. As in all healthcare environments clinical incident reporting in A&E is an important tool for detecting safety issues which can result in identifying solutions, learning from error and enhancing patient safety. This tool must be responsive and flexible to the local circumstances and work for the department to support the clinical governance agenda. In this paper, we describe the local processes for reporting and reviewing clinical incidents in one A&E department in a London teaching hospital and report recent changes to the system within the department. We used the historical data recorded on the Trust incident database as a representation of the information that would be available to the department in order to identify the high risk areas. In this paper, we evaluate the internal processes, the information available on the database and make recommendations to assist the emergency department in their internal processes. These will strengthen the internal review and staff feedback system so that the department can learn from incidents in a consistent manner. The process was reviewed by detailed examination of the centrally held electronic record (Datix database) of all incidents reported in a one year period. The nature of the incident and the level and accuracy of information provided in the incident reports was evaluated. There were positive aspects to the established system including evidence of positive changes made as a result of the reporting process, new initiatives to feedback to staff, and evolution of the programme for reporting and discussing the incidents internally. There appeared to be a mismatch between the recorded events and the category allocated to the incident in the historical record. In addition the database did not contain complete information for every incident, contributory factors were rarely recorded and relatively large numbers of incidents were recorded as "other" in the type of incident. There was also observed difficulty in updating the system as there is at least a months time lag between reporting or an incident and discussion/resolution of issues at the local departmental clinical risk management committee meetings. We used Leape's model for assessing the reporting system as a whole and found the system in the department to be relatively safe, fairly easy to use and moderately effective. Recommendations as a result of this study include the introduction of an electronic reporting system, limiting the number of staff who categorise the incidents--using clear definitions for classifications including a structured framework for contributory factors, and a process that allows incidents to be updated on the database locally after the discussion. This research may have implications for the incident reporting process in other specialities as well as in other hospitals.
现代医疗系统需要更加关注提高患者安全,而实现这一目标的第一步是可靠地识别医疗保健中出现的安全问题。研究表明,急诊(A&E)部门是一个特别存在问题的环境,由于各种因素,如就诊病情的范围、性质和紧迫性以及患者的高周转率,安全成为一个令人担忧的问题。与所有医疗环境一样,急诊部门的临床事件报告是检测安全问题的重要工具,这些问题可能会导致识别解决方案、从错误中吸取教训并提高患者安全。这个工具必须适应当地情况并具有灵活性,以便为该部门服务,支持临床治理议程。在本文中,我们描述了伦敦一家教学医院的一个急诊部门报告和审查临床事件的当地流程,并报告了该部门内系统的近期变化。我们使用信托事件数据库中记录的历史数据来代表该部门可获得的信息,以识别高风险领域。在本文中,我们评估内部流程、数据库中可用的信息,并提出建议以协助急诊科进行内部流程。这些将加强内部审查和员工反馈系统,以便该部门能够以一致的方式从事件中吸取教训。通过详细检查一年内报告的所有事件的中央保存电子记录(Datix数据库)对该过程进行了审查。评估了事件的性质以及事件报告中提供的信息的级别和准确性。既定系统有积极的方面,包括报告过程导致的积极变化的证据、向员工反馈的新举措以及内部报告和讨论事件的计划的演变。记录的事件与历史记录中分配给该事件的类别之间似乎存在不匹配。此外,数据库并未包含每个事件的完整信息,促成因素很少被记录,并且相当数量的事件在事件类型中被记录为“其他”。还观察到更新系统存在困难,因为从报告事件到当地部门临床风险管理委员会会议讨论/解决问题之间至少有一个月的时间滞后。我们使用利普的模型来评估整个报告系统,发现该部门的系统相对安全、相当易于使用且中等有效。这项研究的结果包括引入电子报告系统、限制对事件进行分类的人员数量——使用明确的分类定义,包括促成因素的结构化框架,以及一个允许在讨论后在本地数据库中更新事件的流程。这项研究可能对其他专科以及其他医院的事件报告过程产生影响。