Wallace Louise M, Spurgeon Peter, Benn Jonathan, Koutantji Maria, Vincent Charles
Applied Research Centre Health and Lifestyles Interventions, Coventry University, Coventry, UK.
Health Serv Manage Res. 2009 Aug;22(3):129-35. doi: 10.1258/hsmr.2008.008019.
This paper describes practical implications and learning from a multi-method study of feedback from patient safety incident reporting systems. The study was performed using the Safety Action and Information Feedback from Incident Reporting model, a model of the requirements of the feedback element of a patient safety incident reporting and learning system, derived from a scoping review of research and expert advice from world leaders in safety in high-risk industries. We present the key findings of the studies conducted in the National Health Services (NHS) trusts in England and Wales in 2006. These were a survey completed by risk managers for 351 trusts in England and Wales, three case studies including interviews with staff concerning an example of good practice feedback and an audit of 90 trusts clinical risk staff newsletters. We draw on an Expert Workshop that included 71 experts from the NHS, from regulatory bodies in health care, Royal Colleges, Health and Safety Executive and safety agencies in health care and high-risk industries (commercial aviation, rail and maritime industries). We draw recommendations of enduring relevance to the UK NHS that can be used by trust staff to improve their systems. The recommendations will be of relevance in general terms to health services worldwide.
本文描述了从患者安全事件报告系统反馈的多方法研究中获得的实际意义和经验教训。该研究使用了事件报告中的安全行动与信息反馈模型，这是一种患者安全事件报告与学习系统反馈要素要求的模型，它源自对高风险行业安全领域全球领先者的研究进行的范围审查以及专家建议。我们展示了2006年在英格兰和威尔士的国民医疗服务体系（NHS）信托机构中开展的研究的主要发现。这些研究包括由风险管理人员针对英格兰和威尔士的351家信托机构完成的一项调查、三个案例研究（包括就良好实践反馈的一个例子对工作人员进行访谈）以及对90家信托机构临床风险工作人员通讯的一次审核。我们借鉴了一次专家研讨会的成果，该研讨会有来自NHS、医疗保健监管机构、皇家医学院、健康与安全执行局以及医疗保健和高风险行业（商业航空、铁路和海运行业）安全机构的71名专家参加。我们得出了对英国NHS具有持久相关性的建议，信托机构工作人员可利用这些建议来改进他们的系统。这些建议总体上对全球卫生服务也具有相关性。
