Department of Sociology, Purdue University, West Lafayette, IN 47907-2059, USA.
Health Care Manag Sci. 2010 Mar;13(1):74-83. doi: 10.1007/s10729-009-9111-1.
Inter-organizational systems for sharing data about medication errors have emerged as an important strategy for improving patient safety and are expected to encourage not only voluntary error reporting but also learning from errors. Yet, few studies have examined the hypothesized benefits of inter-organizational data sharing. The current study examined the developmental trends in information reported by hospitals participating in a regional reporting system for medication errors. A coalition of hospitals in southwestern Pennsylvania, under the auspices of the Pittsburgh Regional Healthcare Initiative (PRHI), implemented a voluntary system for quarterly sharing of information about medication errors. Over a 12-month period, 25 hospitals shared information about 17,000 medication errors. Using latent growth curve analysis, we examined longitudinal trends in the quarterly number of errors and associated corrective actions reported by each hospital. Controlling for size, teaching status, and JCAHO accreditation score, for the hospitals as a group, error reporting increased at a statistically significant rate over the four quarters. Moreover, despite significant baseline differences among hospitals, error reporting increased at similar rates across hospitals over subsequent quarters. In contrast, the reporting of corrective actions remained unchanged. However, the baseline levels of corrective actions reporting were significantly different across hospitals. Although data sharing systems promote error reporting, it is unclear whether they encourage corrective actions. If data sharing is intended to promote not just error reporting but also root-cause-analysis and process improvement, then the design of the reporting system should emphasize data about these processes as well as errors.
医疗机构间分享用药错误数据的系统已经成为提高患者安全的一项重要策略,预计不仅能鼓励自愿报告错误,还能从错误中学习。然而,很少有研究检验过医疗机构间数据共享的假设益处。本研究考察了参与用药错误区域报告系统的医院所报告信息的发展趋势。在匹兹堡地区医疗保健倡议(PRHI)的主持下,宾夕法尼亚州西南部的一个医院联盟实施了一项针对用药错误的季度信息自愿共享系统。在 12 个月的时间里,25 家医院分享了约 17000 例用药错误的信息。通过潜在增长曲线分析,我们考察了每个医院每季度报告的错误数量和相关纠正措施的纵向趋势。在控制了规模、教学地位和 JCAHO 认证评分后,就医院整体而言,错误报告在四个季度内以统计学显著的速度增加。此外,尽管医院之间存在显著的基线差异,但在随后的几个季度中,错误报告的增长率在各医院之间基本一致。相比之下,纠正措施的报告保持不变。然而,各医院之间的纠正措施报告的基线水平存在显著差异。尽管数据共享系统促进了错误报告,但尚不清楚它们是否鼓励了纠正措施。如果数据共享不仅旨在促进错误报告,还旨在促进根本原因分析和流程改进,那么报告系统的设计就应该强调这些流程以及错误的数据。