Kim Jeongeun, Kim Sukwha, Jung Yoenyi, Kim Eun-Kyung
College of Nursing, Seoul National University, Seoul, Korea.
Healthc Inform Res. 2010 Sep;16(3):166-76. doi: 10.4258/hir.2010.16.3.166. Epub 2010 Sep 30.
This study identifies the current status and problems of adverse event reporting system in Korean hospitals. The data obtained from this study will be used to raise international awareness and enable collaborative researches on patient safety.
We distributed the questionnaire developed by the Agency for Healthcare Research and Quality (AHRQ), USA to the 265 risk managers of hospitals by e-mail. Seventy-two percent of the risk managers responded to the inquiry.
Eighty-five percent of the hospitals responded that they collect information regarding the event where harm has occurred or might have occurred to a patient. Seventy-five percent of the hospitals did not allow individuals to report occurrences without identifying themselves. Only 54% of the hospitals had an organized patient safety program that manages or coordinates all of the hospital's patient safety activities. The most frequent reason why errors were not reported was the fear of individuals being involved in the investigation and potential disadvantage resulting from it. Eighty-five percent of the hospitals produced reports of their adverse event data, but 68% of the hospitals did not distribute occurrence reports within the hospital.
Lack of standardized reporting system, available information, procedures for protecting the reporting individuals, and mindlessness/indifference of the hospital employees are identified as the major problems. Therefore, it is crucial to address these problems to develop appropriate solutions, enable proactive involvement from the healthcare community, and change the overall patient safety culture, specifically protecting privacy, to increase the quality of service in the healthcare industry.
本研究旨在确定韩国医院不良事件报告系统的现状和问题。本研究获得的数据将用于提高国际关注度，并促进关于患者安全的合作研究。
我们通过电子邮件向265家医院的风险管理人员发放了由美国医疗保健研究与质量局（AHRQ）编制的调查问卷。72%的风险管理人员回复了调查。
85%的医院表示他们会收集有关患者已发生或可能发生伤害事件的信息。75%的医院不允许个人在不表明身份的情况下报告事件。只有54%的医院有一个有组织的患者安全计划来管理或协调医院所有的患者安全活动。未报告错误的最常见原因是担心个人卷入调查以及由此产生的潜在不利影响。85%的医院生成了不良事件数据报告，但68%的医院未在医院内部分发事件报告。
缺乏标准化报告系统、可用信息、保护报告人的程序以及医院员工的疏忽/冷漠被确定为主要问题。因此，解决这些问题对于制定适当的解决方案、促使医疗界积极参与以及改变整体患者安全文化（特别是保护隐私）以提高医疗行业的服务质量至关重要。
