Kievit J, Krukerink M, Marang-van de Mheen P J
Department of Medical Decision Making, Leiden University Medical Centre, The Netherlands.
Qual Saf Health Care. 2010 Dec;19(6):e20. doi: 10.1136/qshc.2008.027458. Epub 2010 Apr 29.
In The Netherlands, health professionals have created a doctor-driven standardised system to report and analyse adverse outcomes (AO). The aim is to improve healthcare by learning from past experiences. The key elements of this system are (1) an unequivocal definition of an adverse outcome, (2) appropriate contextual information and (3) a three-dimensional hierarchical classification system.
First, to assess whether routine doctor-driven AO reporting is feasible. Second, to investigate how doctors can learn from AO reporting and analysis to improve the quality of care.
Feasibility was assessed by how well doctors reported AO in the surgical department of a Dutch university hospital over a period of 9 years. AO incidence was analysed per patient subgroup and over time, in a time-trend analysis of three equal 3-year periods. AO were analysed case by case and statistically, to learn lessons from past events.
In 19,907 surgical admissions, 9189 AOs were reported: one or more AO in 18.2% of admissions. On average, 55 lessons were learnt each year (in 4.3% of AO). More AO were reported in P3 than P1 (OR 1.39 (1.23-1.57)). Although minor AO increased, fatal AO decreased over time (OR 0.59 (0.45-0.77)).
Doctor-driven AO reporting is shown to be feasible. Lessons can be learnt from case-by-case analyses of individual AO, as well as by statistical analysis of AO groups and subgroups (illustrated by time-trend analysis), thus contributing to the improvement of the quality of care. Moreover, by standardising AO reporting, data can be compared across departments or hospitals, to generate (confidential) mirror information for professionals cooperating in a peer-review setting.
在荷兰，医疗专业人员创建了一个由医生主导的标准化系统，用于报告和分析不良事件（AO）。目的是通过吸取过去的经验教训来改善医疗保健。该系统的关键要素包括：（1）对不良事件的明确界定；（2）适当的背景信息；（3）三维分层分类系统。
第一，评估由医生主导的常规不良事件报告是否可行。第二，调查医生如何通过不良事件报告和分析来提高医疗质量。
通过荷兰一家大学医院外科部门的医生在9年期间对不良事件的报告情况来评估可行性。在三个相等的3年时间段的时间趋势分析中，按患者亚组并随时间分析不良事件发生率。对不良事件进行逐案分析和统计分析，以吸取过去事件的教训。
在19907例外科住院病例中，报告了9189起不良事件：18.2%的住院病例发生了一起或多起不良事件。平均每年吸取55个教训（占不良事件的4.3%）。与P1相比，P3报告的不良事件更多（比值比1.39（1.23 - 1.57））。尽管轻微不良事件有所增加，但致命不良事件随时间减少（比值比0.59（0.45 - 0.77））。
由医生主导的不良事件报告是可行的。可以从对单个不良事件的逐案分析以及对不良事件组和亚组的统计分析（通过时间趋势分析说明）中吸取教训，从而有助于提高医疗质量。此外，通过标准化不良事件报告，可以跨部门或医院比较数据，为在同行评审环境中合作的专业人员生成（保密的）镜像信息。
