Julius Center for Health Sciences and Primary Care and Patient Safety Center, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands.
BMJ Qual Saf. 2011 Feb;20(2):121-7. doi: 10.1136/bmjqs.2009.033472. Epub 2011 Jan 5.
To evaluate the feasibility of a locally implemented incident-reporting procedure (IRP) in primary healthcare centres after 1 year.
Five primary healthcare centres caring for more than 43000 patients in The Netherlands. GPs, medical nurses, physiotherapists, pharmacists, pharmacist assistants and trainees reported incidents (a total of 117 employees).
An IRP was implemented in which participants were encouraged to report all incidents. In addition, dedicated 'reporting weeks' were introduced that emphasised reporting of minor incidents and near misses. In every centre, an IRP committee analysed the reported incidents in order to initiate improvements when necessary.
Frequency and nature of reported incidents, number of incidents analysed by the IRP committees and number of improvements implemented. In addition, the authors studied the actual implementation of the IRP and the acceptability as experienced by participants.
A total of 476 incidents were reported during a 9-month reporting period. Of all incidents, 62% were reported in a reporting week, and most were process-related. Possible harm for patients was none or small in 87% of the reported incidents. IRP committees analysed 84 incidents and found 230 root causes. All participating centres had initiated improvement projects as a result of reported incidents. Most interviewees considered the IRP feasible, but several practical, professional and personal barriers to implementation of the IRP were identified.
The implementation of a centre-based IRP in primary care is feasible. Reporting weeks enhance the willingness to report.
评价在荷兰的 5 家初级保健中心实施的局部事件报告程序（IRP）在实施 1 年后的可行性。
5 家初级保健中心，每家保健中心照顾 43000 多名患者以上，共 117 名员工，包括全科医生、医护人员、物理治疗师、药剂师、药剂师助理和实习生。
实施了 IRP，鼓励参与者报告所有事件。此外，还引入了专门的“报告周”，强调报告轻微事件和未遂事件。每个中心的 IRP 委员会都会分析报告的事件，以在必要时启动改进措施。
在 9 个月的报告期内，共报告了 476 起事件。所有事件中，62%是在报告周内报告的，大多数与流程有关。在报告的事件中，87%的患者可能受到的伤害为无或小。IRP 委员会分析了 84 起事件，发现了 230 个根本原因。所有参与中心都因报告的事件启动了改进项目。大多数受访者认为 IRP 是可行的，但也确定了实施 IRP 的一些实际、专业和个人障碍。
在初级保健中实施基于中心的 IRP 是可行的。报告周增强了报告的意愿。
