为事件报告系统建立一个全球学习社区。
Establishing a global learning community for incident-reporting systems.
作者信息
Pham Julius Cuong, Gianci Sebastiana, Battles James, Beard Paula, Clarke John R, Coates Hilary, Donaldson Liam, Eldridge Noel, Fletcher Martin, Goeschel Christine A, Heitmiller Eugenie, Hensen Jörgen, Kelley Edward, Loeb Jerod, Runciman William, Sheridan Susan, Wu Albert W, Pronovost Peter J
机构信息
The Johns Hopkins University School of Medicine, 1909 Thames Street, 2nd Floor, Baltimore, MD 21231, USA.
出版信息
Qual Saf Health Care. 2010 Oct;19(5):446-51. doi: 10.1136/qshc.2009.037739.
BACKGROUND
Incident-reporting systems (IRS) collect snapshots of hazards, mistakes and system failures occurring in healthcare. These data repositories are a cornerstone of patient safety improvement. Compared with systems in other high-risk industries, healthcare IRS are fragmented and isolated, and have not established best practices for implementation and utilisation.
DISCUSSION
Patient safety experts from eight countries convened in 2008 to establish a global community to advance the science of learning from mistakes. This convenience sample of experts all had experience managing large incident-reporting systems. This article offers guidance through a presentation of expert discussions about methods to identify, analyse and prioritise incidents, mitigate hazards and evaluate risk reduction.
背景
事件报告系统（IRS）收集医疗保健中发生的危害、失误和系统故障的即时情况。这些数据库是改善患者安全的基石。与其他高风险行业的系统相比，医疗保健IRS分散且孤立，尚未确立实施和利用的最佳做法。
讨论
来自八个国家的患者安全专家于2008年召开会议，建立了一个全球社区，以推进从失误中学习的科学。这个由专家组成的便利样本都有管理大型事件报告系统的经验。本文通过介绍专家关于识别、分析和确定事件优先级、减轻危害以及评估风险降低方法的讨论，提供指导。
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