Flemons W Ward, McRae Glenn
University of Calgary, Foothills Medical Centre, Calgary, Alberta.
Healthc Q. 2012;15 Spec No:12-7. doi: 10.12927/hcq.2012.22847.
Systems that provide healthcare workers with the opportunity ot report hazards, hazardous situations errors, close calls and adverse events make it possible for an organization that receives such reports tu use these opportunities to learn and /or hold people accountable for their actions. When organizational learning is the primary goal, reporting should be confidential, voluntary and easy to perform and should lead to risk mitigation strategies following appropriate analysis; conversely, when the goal is accountability, reporting is more likely to be made mandatory. reporting systems do not necessarily equate to safer patient care and have been criticized for capturing too many mundane events but only a small minority of important events. reporting has been inappropriately equated with patients safety activity and mistakenly used for "measuring" system safety. However, if properly designed and supported, a reporting system can be an important component of an organizational strategy ot foster a safety culture.
为医护人员提供报告危险、危险情况、差错、险情和不良事件机会的系统，能使接收此类报告的组织利用这些机会进行学习和/或追究相关人员的行为责任。当组织学习是主要目标时，报告应保密、自愿且易于操作，并应在适当分析后形成风险缓解策略；相反，当目标是追究责任时，报告更可能成为强制性要求。报告系统不一定等同于更安全的患者护理，且因记录了过多日常事件但仅少量重要事件而受到批评。报告被不恰当地等同于患者安全活动，并被错误地用于“衡量”系统安全。然而，如果设计和支持得当，报告系统可以成为组织培养安全文化战略的重要组成部分。
