Kanda Hirohito
Department of Pharmacy, University Hospital, Shinshu University School of Medicine, Nagano, Japan.
Yakugaku Zasshi. 2011;131(9):1353-9. doi: 10.1248/yakushi.131.1353.
To minimize their occurrence, it is important to gather and analyze data regarding cases of not only medical accidents but also of incidents involving potential harm to patients. In gathering data, we have separated reporting between the details of such incidents and information about their occurrence. We have implemented a system involving a first report to achieve prompt notification and a second report to provide details. An online report input system has been established taking into consideration both ease of input and promptness of information sharing. We discuss the input of the first and second reports in a total of 951 cases over a period of 6 months. From the data regarding the timing of the first report, 307 and 789 cases were reported within 24 h and 48 h, respectively, indicating that the first report was input mostly without delay in accordance with the operational guidelines. On the other hand, it took 14 days to surpass a second report rate of 80%. Cases that took more than 2 weeks to be reported would likely have gone unreported had there not been a first report to indicate and confirm that an incident had even occurred. Investigation is needed, especially for problematic cases, so we assume that discovering important incidents via the first report has been successful. In addition, details of incidents can be input into this system in free-text, yielding information that cannot be acquired with multiple choice input as in standard reporting systems.
为尽量减少此类事件的发生,收集和分析不仅关于医疗事故,还包括涉及对患者潜在伤害事件的数据非常重要。在收集数据时,我们将此类事件的细节报告与事件发生信息分开报告。我们实施了一个系统,包括用于快速通知的首次报告和用于提供详细信息的二次报告。已建立一个在线报告输入系统,兼顾输入的便捷性和信息共享的及时性。我们讨论了6个月内共951例病例的首次和二次报告输入情况。从首次报告的时间数据来看,分别有307例和789例在24小时和48小时内报告,这表明首次报告大多是按照操作指南及时输入的。另一方面,超过80%的二次报告率用了14天时间。如果没有首次报告来表明并确认事件的发生,那些超过两周才报告的病例可能就不会被报告了。特别是对于有问题的病例需要进行调查,所以我们认为通过首次报告发现重要事件是成功的。此外,事件细节可以以自由文本形式输入该系统,从而产生标准报告系统中多项选择输入无法获取的信息。