Levtzion-Korach Osnat, Frankel Allan, Alcalai Hanna, Keohane Carol, Orav John, Graydon-Baker Erin, Barnes Janet, Gordon Kathleen, Puopulo Anne Louise, Tomov Elena Ivanova, Sato Luke, Bates David W
Division of General Internal Medicine, Brigham and Women's Hospital, Boston, USA.
Jt Comm J Qual Patient Saf. 2010 Sep;36(9):402-10. doi: 10.1016/s1553-7250(10)36059-4.
A study was conducted to examine and compare information gleaned from five different reporting systems within one institution: incident reporting, patient complaints, risk management, medical malpractice claims, and executive walk rounds. These data sources vary in the timing of the reporting (retrospective or prospective), severity of the events, and profession of the reporters.
A common methodology was developed for classifying incidents. Data specific to each incident were abstracted from each system and then categorized using the same framework into one of 23 categories.
Overall, there was little overlap, although each reporting system identified important safety issues. Communication problems were common among patient complaints and malpractice claims; malpractice claims' leading category was clinical judgement. Walk rounds identified issues with equipment and supplies. Adverse event reporting systems highlighted identification issues, especially mislabelled specimens. The frequency of contributions of reports by provider group varied substantially by system. Physicians accounted for 50% of risk management reports, but in adverse event reporting, where nurses were the main reporters, physicians accounted for only 2.5% of reports. Complaints and malpractice claims come primarily from patients.
The five reporting systems each identified different yet complementary patient safety issues. To obtain a comprehensive picture of their patient safety problems and to develop priorities for improving safety, hospitals should use a broad portfolio of approaches and then synthesize the messages from all individual approaches into a collated and cohesive whole.
开展了一项研究，以检查和比较从一家机构内五个不同报告系统收集到的信息：事件报告、患者投诉、风险管理、医疗事故索赔和行政巡查。这些数据源在报告时间（回顾性或前瞻性）、事件严重程度和报告者职业方面存在差异。
开发了一种用于对事件进行分类的通用方法。从每个系统中提取每个事件的特定数据，然后使用相同框架将其分类为23个类别之一。
总体而言，尽管每个报告系统都识别出了重要的安全问题，但重叠较少。沟通问题在患者投诉和医疗事故索赔中很常见；医疗事故索赔的主要类别是临床判断。巡查发现了设备和物资方面的问题。不良事件报告系统突出了识别问题，尤其是标本标签错误。按提供者群体划分的报告贡献频率在不同系统中差异很大。医生占风险管理报告的50%，但在以护士为主要报告者的不良事件报告中，医生仅占报告的2.5%。投诉和医疗事故索赔主要来自患者。
这五个报告系统各自识别出了不同但互补的患者安全问题。为了全面了解其患者安全问题并确定改善安全的优先事项，医院应采用广泛的方法组合，然后将所有个别方法的信息综合成一个整理好的、连贯的整体。
