Department of Educational Development and Research, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.
PLoS One. 2012;7(2):e31125. doi: 10.1371/journal.pone.0031125. Epub 2012 Feb 16.
Incident reporting systems (IRS) are used to identify medical errors in order to learn from mistakes and improve patient safety in hospitals. However, IRS contain only a small fraction of occurring incidents. A more comprehensive overview of medical error in hospitals may be obtained by combining information from multiple sources. The WHO has developed the International Classification for Patient Safety (ICPS) in order to enable comparison of incident reports from different sources and institutions.
The aim of this paper was to provide a more comprehensive overview of medical error in hospitals using a combination of different information sources. Incident reports collected from IRS, patient complaints and retrospective chart review in an academic acute care hospital were classified using the ICPS. The main outcome measures were distribution of incidents over the thirteen categories of the ICPS classifier "Incident type", described as odds ratios (OR) and proportional similarity indices (PSI).
A total of 1012 incidents resulted in 1282 classified items. Large differences between data from IRS and patient complaints (PSI = 0.32) and from IRS and retrospective chart review (PSI = 0.31) were mainly attributable to behaviour (OR = 6.08), clinical administration (OR = 5.14), clinical process (OR = 6.73) and resources (OR = 2.06).
IRS do not capture all incidents in hospitals and should be combined with complementary information about diagnostic error and delayed treatment from patient complaints and retrospective chart review. Since incidents that are not recorded in IRS do not lead to remedial and preventive action in response to IRS reports, healthcare centres that have access to different incident detection methods should harness information from all sources to improve patient safety.
事故报告系统（IRS）用于识别医疗差错，以便从错误中吸取教训，提高医院患者安全。然而，IRS 只包含发生事件的一小部分。通过整合来自多个来源的信息，可以更全面地了解医院的医疗错误。为了能够比较来自不同来源和机构的事故报告，世界卫生组织（WHO）开发了《国际患者安全分类》（ICPS）。
本文的目的是使用不同信息源的组合提供对医院医疗错误的更全面概述。使用 ICPS 对 IRS、患者投诉和学术急症医院的回顾性图表审查中收集的事故报告进行分类。主要观察指标是 ICPS 分类器“事件类型”中事件的分布，描述为比值比（OR）和比例相似性指数（PSI）。
共收集到 1012 起事故，导致 1282 个分类项目。IRS 与患者投诉（PSI=0.32）和 IRS 与回顾性图表审查（PSI=0.31）之间的数据差异较大，主要归因于行为（OR=6.08）、临床管理（OR=5.14）、临床流程（OR=6.73）和资源（OR=2.06）。
IRS 不能捕获医院中的所有事件，应与来自患者投诉和回顾性图表审查的关于诊断错误和延迟治疗的补充信息相结合。由于 IRS 中未记录的事件不会导致针对 IRS 报告采取补救和预防措施，因此拥有不同事件检测方法的医疗中心应利用所有来源的信息来提高患者安全。
