Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA 02120, USA.
J Patient Saf. 2009 Mar;5(1):9-15. doi: 10.1097/PTS.0b013e318198dc8d.
Incident reporting represents a key tool in safety improvement. Electronic voluntary reporting systems have been perceived as advantageous compared to paper approaches and are increasingly being implemented.
To evaluate the rate, content, ease of use, reporters' profile, and the follow-up and actions resulting from reports submitted to a Web-based electronic reporting system.
Analysis of the submitted reports to a commercial Web-based reporting system at a tertiary care academic hospital for 31 months between May 2004 and November 2006.
During the study period, 14,179 reports were submitted. The leading incident categories were labs (30%), followed by medication issues (17%), falls (11%), and blood bank (10%). Of the reported incidents, 24% were near misses, 61% were adverse events that caused no harm, 14% caused temporary harm, 0.4% caused permanent harm, and 0.1% caused death. Of the eligible staff, 29% submitted a report during the study period. Physicians submitted only 2.9% of the reports; most reports were submitted by nurses, pharmacists, and technicians. Physicians tended to report on more severe cases and focused on different topics than other professionals. Overall, 84% of the reports came from the inpatient setting. On average, it took 14 minutes to submit a report. In following up on reports, first manager review was completed within a median of 22 hours, and a mean of 4 people reviewed each report. A large array of actions followed the reports.
This application effectively captured incidents, actions, and follow-up. Ease of data manipulation facilitated descriptive statistical analysis, and the ability to use branching algorithms may have helped in decision making about actions and follow-up.
事件报告是改进安全的重要手段。与纸质方法相比，电子自愿报告系统被认为具有优势，并且越来越多地被采用。
评估提交给基于网络的电子报告系统的报告的发生率、内容、易用性、报告者特征以及报告所产生的后续行动和措施。
对 2004 年 5 月至 2006 年 11 月期间在一家三级保健学术医院使用商业性基于网络的报告系统提交的报告进行分析。
在研究期间，共提交了 14179 份报告。主要的事件类别为实验室（30%），其次是用药问题（17%）、跌倒（11%）和血库（10%）。所报告的事件中，24%为未遂差错，61%为未造成伤害的不良事件，14%造成暂时伤害，0.4%造成永久伤害，0.1%造成死亡。在符合条件的员工中，29%在研究期间提交了报告。医生仅提交了报告的 2.9%；大多数报告由护士、药剂师和技术人员提交。医生倾向于报告更严重的病例，关注的主题与其他专业人员不同。总体而言，84%的报告来自住院部。平均而言，提交一份报告需要 14 分钟。在对报告进行跟踪时，第一经理审查在中位数为 22 小时内完成，平均有 4 人审查每份报告。在报告之后采取了大量措施。
该应用程序有效地捕获了事件、行动和后续行动。易于进行数据操作有助于进行描述性统计分析，并且能够使用分支算法可能有助于决策后续行动。
