Eadie Anne
Dundee University, Dundee, United Kingdom.
J Forensic Leg Med. 2012 Oct;19(7):437-41. doi: 10.1016/j.jflm.2012.04.007. Epub 2012 May 16.
Healthcare professionals have an ethical and professional responsibility to report medical errors. Doctors in particular are duty bound to consider the best interests of their patients and 'do no harm'. Medical errors are rarely due to individual human error but are often systems based and in many cases are avoidable. Reporting and learning from medical errors improves the safety of patients. It has been over ten years since the reports To Err Is Human and An Organisation with a Memory highlighted the scale of preventable medical errors. These statistics, stimulated worldwide health organisations to prioritise patient safety. Both reports recommended the implementation of a voluntary near-miss reporting system and mandatory reporting of serious adverse incidents that had caused physical or psychological harm or death. Currently in Scotland reporting of all errors is voluntary and there is no sharing of information between Health Boards. Studies have demonstrated failings of the voluntary system and preventable medical errors are still occurring in Scotland. The UK Government in England as of April 2010 has changed the voluntary system of reporting serious adverse events to a mandatory obligation. Failure to report may result in a fine of £4000 to the Trust. Patient groups wish the system in Scotland to become mandatory with public disclosure. This would ensure openness, honesty and autonomy for patients. This article reviews the controversial issue of mandatory reporting and whether or not this would improve the safety of patients. In conclusion, Scotland would benefit from mandatory reporting of serious adverse events and voluntary near-miss reporting.
医疗保健专业人员在报告医疗差错方面负有道德和职业责任。尤其是医生,有责任考虑患者的最大利益并“不造成伤害”。医疗差错很少是由于个人人为失误造成的,而往往是基于系统问题,并且在许多情况下是可以避免的。报告医疗差错并从中吸取教训可提高患者的安全性。自《人皆会犯错》和《有记忆的组织》两份报告突出了可预防医疗差错的规模以来,已经过去了十多年。这些统计数据促使全球卫生组织将患者安全列为优先事项。两份报告都建议实施自愿性的未遂事件报告系统,并对造成身体或心理伤害或死亡的严重不良事件进行强制性报告。目前在苏格兰,所有差错的报告都是自愿的,而且卫生委员会之间不共享信息。研究表明自愿报告系统存在缺陷,可预防的医疗差错在苏格兰仍在发生。截至2010年4月,英国政府在英格兰已将严重不良事件的自愿报告系统改为强制性义务。未能报告可能会导致信托机构被罚款4000英镑。患者团体希望苏格兰的该系统成为强制性的并进行公开披露。这将确保患者的公开性、诚实性和自主性。本文回顾了强制性报告这一有争议的问题,以及这是否会提高患者的安全性。总之,苏格兰将从严重不良事件的强制性报告和未遂事件的自愿报告中受益。